
Glass -jLX-O 

Book J^H__ 

Copyright N° 

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DIAGNOSTICS 



OF THE 



DISEASES OF CHILDREN 



BY 



LE GRAND KERR, M.D. 



PROFESSOR OF THE DISEASES OF CHILDREN IN THE BROOKLYN POSTGRADUATI 

MEDICAL SCHOOL; PEDIATRIST TO THE SWEDISH HOSPITAL IN BROOKLYN; 

ATTENDING PEDIATRIST TO THE WILLIAMSBURG HOSPITAL, BROOKLYN 



FULLY ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1907 



¥".-;■ 



-f. 



i 






A 



K- 



LIBRARY of CONGRESS 
Two Copies Received 

APft 9 1907 

^ Copyright Entry 

.AX, i-^3, '?o/ 

CLASS A XXCn No 



(£"7- 



Copyright, 1907, by W. B. Saunders Company 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



PREFACE 



Diagnosis of disease in the adult takes advantage of the 
subjective as well as of the objective symptoms. And in nearly 
every instance the physician may secure a clear history of the 
present and previous conditions. 

But diagnosis of disease, or the discovery of conditions which 
may lead to the establishment of disease in the infant and child, 
encounters many difficulties. The infant cannot define his feel- 
ings, and the accuracy of the older child's definition is propor- 
tionate to its intellectual development. For information as 
to the child's feelings and the history of the condition the physi- 
cian is in great measure dependent upon the observations of an 
over-anxious parent or a disinterested nurse-maid, and under 
ordinary circumstances either of such observers is apt to be 
inaccurate. 

Confined, therefore, largely to the objective symptoms of 
disease, their correct interpretation is of absolute importance. 
For this reason among others I was led to write upon this subject. 
It is my hope that this volume may be the means of stimulating 
a closer study of the child life; may, in short, do something to 
secure for the child a "square deal" in the practice of medicine. 

One aim has been kept constantly in view — to be practical, 
to help those who are engaged in the general practice of medi- 
cine to an early recognition of disease when it occurs in a child. 
Just so much of etiology and pathology have been introduced 
as is useful in diagnosis, and the sequelae of diseases are considered 
only as they are helpful in the identification of immediate or 
possible dangers. It has been my endeavor to approach the 
subject as the child is approached in the sick-room, with the 
idea of arriving at right conclusions. 

The usual custom of dividing the work into two parts, con- 
sidering differential diagnosis separately, has not been followed. 

7 



8 PREFACE 

I have tried to impress the importance of an early diagnosis 
by taking up the differential diagnosis even under the circum- 
stances where there are present only the few symptoms of the onset 
of some disease. Under appropriate headings ^he symptoma- 
tology of each disease is fully discussed, so that its recognition 
may be marked clearly. 

A large part of what is worth while in what a man says and 
does has been caught by the contagion of great characters in 
great teachers and great books. It may be that these teachers 
have "gone on before" and that their books are out-of-date, 
but their influence abides. For the inspiration of these men 
and their books, the encouragement of my fellow-practitioners 
and friends, and for the appeal of the mother's words and eyes 
which have driven me to harder endeavor, I am profoundly 
grateful. 

I would especially acknowledge the great kindness of Dr. C. 
B. Bacon and Dr. N. T. Beers, for suggestions and help in the 
making of photographs for use in this volume, and to Dr. C. D. 
Napier, Dr. J. M. Winfield, and Dr. G. F. Little, for the use of 
illustrations. 

I would err in gratitude if I failed to acknowledge the uniform 
courtesy and hearty cooperation of my publishers, who not only 
do, but are cheerful in the doing. 

LeGrand Kerr. 

110 Cumberland Street, Brooklyn, New York. 



CONTENTS 



PAGE 

Examination 17 

The approach to the child — The history of the present illness — 
The age — The previous condition — The teeth. 

General Posture 24 

The side position- — The dorsal position — On the abdomen — 
Forced positions — The upright or sitting position. 

Facial Expression 25 

Normal expression — Normal expression plus twitching — Normal 
expression with eyelids parted — Listlessness — Vacant expres- 
sion — Idiotic — Anxious — Old expression — Expressionless — 
Painful disfiguration. 

The Face as Indicative of Disease 28 

Nephritis — Pertussis — Hereditary syphilis — Tubercular bone 
disease — Chronic malaria— Mouth-breathers — Cretinism. 

The Body Weight 29 

Normal conditions — Loss of weight — Gradual loss — Relative 
loss — Steady loss — Rapid loss — Stationary weight — Rapid gain. 

Sleep 36 

Normal sleep — Disturbed sleep — Restless sleep — Uneasy sleep — 
Night terrors — Excessive sleep — Drowsiness — Somnambulism. 

The Head 40 

Shape — Asymmetry — Size — Gradual enlargement — Rapid en- 
largement — Small size — Baldness of occiput — Sweating of head. 

The Fontanels 43 

Normal conditions — Delayed closure — Slightly bulging — Tense 
and bulging — Sunken — Murmuring. 

Craniotabes 45 

Tumors of the Head 45 

Caput succedaneum — Cephalhematoma — Meningocele — Enceph- 
alocele — Hydrencephalocele — Pneumatocele cranii. 

Examination of the Nose 4S 

Pain about the nose — Nasal stenosis — Nasal discharge — Acute 
rhinitis — Adenoid vegetations — Membranous rhinitis — Chronic 
rhinitis — Hereditary syphilis — Atrophic rhinitis — Foreign body 
— Nasal polypi. 

Epistaxis 56 

Diagnosis — General causes — Local causes. 

Examination of the Lips, Tongue, and Mouth 59 

Malformations — Harelip — Cleft palate— Hypertrophy of the 
tongue — Tongue tie — Bifid uvula — Bifid tongue. 

The Lips 59 

Color — Unilateral deviation — Open lips — Swollen lips Twitch- 
ing lips — Eruptions about the lips — Herpes — Perleche Eczema. 

9 



IO CONTENTS 

PAGE 

The Tongue 61 

Examination — Coated tongue — Manner in which coating clears 
—Dry glazed tongue — Color — Diseases of the tongue — Hyper- 
trophy — Ulcers — Epithelial desquamation — Acute glossitis. 

The Mouth _ 65 

Diseases of the mouth unaccompanied by odor or ulceration. 
Gonorrheal stomatitis — Acute catarrhal stomatitis — Stom- 
atitis mycosa. 

Diseases with ulceration and no offensive odor. 

Stomatitis aphthosa — Syphilitic stomatitis — Aphthae of 
the palate. 

Diseases with ulceration and offensive odor. 

Stomatitis ulcerosa — Stomatitis gangrenosa. 

Diseases with the formation of membrane. 
Stomatitis membranosa. 

The Fauces and Pharynx 72 

Pain — Examination — Normal condition — Diseases of the fauces 
and pharynx — Acute tonsillitis — Simple catarrhal tonsillitis — 
Follicular tonsillitis — Suppurative tonsillitis — Ulceromembran- 
ous tonsillitis — Chronic tonsillitis — Adenoid vegetations — Acute 
pharyngitis — Chronic pharyngitis — Acute uvulitis — Retrophar- 
yngeal lymphadenitis. 

Laryngeal Stenosis 85 

General considerations — Acute stenosis — Catarrhal spasm — 
Membranous laryngitis — Acute catarrhal laryngitis — Edema 
of the glottis — Submucous laryngitis — Foreign body — Retro- 
pharyngeal lymphadenitis — Laryngismus stridulus — Chronic 
stenosis — Chronic laryngitis — Syphilitic laryngitis — Tubercu- 
lous laryngitis — Tumors — Congenital stenosis — Congenital lar- 
yngeal stridor. 

Dysphagia 95 

Diseases of the Esophagus 98 

Malformations — Acute esophagitis — Retroesophageal abscess. 

Appetite and Thirst 100 

Anorexia — Increased appetite — Pica — Thirst. 

Vomiting 104 

Eructations — Vomiting. 

Vomiting accompanied by little or no rise in temperature : 

Habit — Neurotic vomiting — Overdistended stomach — 
Intestinal worms — Following coughing spells. 

Vomiting accompanied by a decided rise of temperature : 

Cerebral vomiting — Scarlet fever — Variola — Peritonitis — 
Pneumonia. 

Vomiting from toxemia : 
Recurrent vomiting. 

Vomiting associated with obstinate constipation: 

Malformations — Intussusception — Impacted feces — Stran- 
gulated hernia — Pyloric stenosis. 

Diseases of the Stomach with Vomiting as a Prominent Symptom . 115 
Acute gastric indigestion — Acute gastritis — Gastroduodenitis — 
Chronic gastric indigestion — Gastric catarrh — Chronic gastri- 
tis — Dilatation of the stomach. 

Character of the Vomitus 119 

Blood — Food — Uncoagulated milk — Food and mucus — Food 
and bile — Pus — Membrane. 

Hemorrhage from the Stomach 122 



CONTENTS 1 1 

PAGE 

Abdominal Pain. 123 

General considerations — Intestinal colic — Appendicitis — Acute 
peritonitis — Catarrh of the small intestine — Catarrh of the large 
intestine — Intussusception — Intestinal parasites — Spinal caries 
— Nephritic colic. 

Examination of the Abdomen 130 

Inspection — Omphalitis — Palpation. 

Enlargement of the Abdomen 133 

Tympanites — Ascites — Hydronephrosis — Distended bladder — 
Chronic (non-tuberculous) peritonitis — Tuberculous peritonitis — 
Malignant tumors of the kidneys — Retroperitoneal sarcoma — 
Tumors of the abdominal wall. 

Enlargement of the Liver 144 

Acute enlargement — Congestion — Suppurative hepatitis — 
Acute infectious liver — Chronic enlargement — Cirrhosis — Amy- 
loid disease — Fatty liver — Leukemic liver — Echinococcus of 
the liver — Syphilis of the liver — Tumors. 

Enlargement of the Spleen 149 

Examination — Acute splenic enlargement — Chronic enlarge- 
ment. 

Diarrhea 153 

Causes of acute diarrhea — Nervous diarrhea — Eliminative diar- 
rhea — Fat diarrhea — Acute intestinal indigestion — Acute gastro- 
enteric infection — Cholera infantum — Acute ileocolitis — Chronic 
diarrhea — Tuberculosis of the intestines and mesenteric glands — 
Chronic ileocolitis — Chronic intestinal indigestion — Malaria. 

Incontinence of the Feces 166 

Painful Defecation 167 

Rectal Tenesmus 168 

Proctitis — Rectal polypi. 

Chronic Constipation 170 

Causes. 

Intestinal Parasites 1 75 

Oxyuris vermicularis — Ascaris lumbricoides — Taenia. 

The Cry and the Voice 176 

The cry — Lusty cry at birth — Weak cry at birth — Loud cry — 
Continued loud cry — Continued suppressed cry — Continued 
low cry — Short violent cry — The voice — Loss of voice and hoarse- 
ness — Nasal voice. 

The Cough 180 

Dry — Moist — Hacking — Laryngeal — Paroxysmal — Sup- 
pressed — Cardiac — Inability to cough. 

Diseases with Cough as the Prominent Symptom 1S3 

Pertussis — Foreign bodies in the trachea or larynx — Trachitis — 
Acute bronchitis — Chronic bronchitis — Bronchiectasis. 

Examination of the Chest 105 

Inspection — Skin and subcutaneous tissues — Shape in health — 
Size — Movements — Changes in the skin and subcutaneous tis- 
sues — Changes in shape and size — Flat — Pigeon chest — Rachitic 
chest — Funnel chest — Emphysematous chest — Unilateral en- 
largement — Unilateral contraction — Precordial bulging — Hypo- 
chondrium bulging — Local depressions — Movements in disease — 
Increased movement of one side — Unilateral diminution of 
movement — Types of respiration: Abdominal; Thoracic ; 



12 CONTENTS 



Cheyne-Stokes breathing; Sighing respiration; Stertorous; 
Stridulous — Palpation — Vocal fremitus — Percussion- — Ausculta- 
tion. 

Dyspnea 208 

Dyspnea upon exertion — Paroxysmal — Inspiratory — Asthma — 
Hay-fever — Pulmonary emphysema — Lobar pneumonia — Bron- 
chopneumonia — Pleuropneumonia — Hypostatic pneumonia — 
Pleuritis. 

The Cutaneous Surface 233 

Color of the skin — Pallor — Yellow tint — Redness — Cyanosis — 

Rashes — Erythematous rashes. 

Erythema of the new-born — Dermatitis exfoliativa — Erysipe- 
las — Localized erythemas — Roseola aestiva — Roseola — Ery- 
thema multiforme — Erythema nodosum — Urticaria — Ery- 
thema scarlatiniforme — Erythema morbilliforme. 

Vesicular rashes. 

Medicinal rashes — Herpes — Sudamina — Varicella. 

Papular eruptions. 

Miliaria rubra — Miliaria papulosa. 

Pustular eruptions. 

Medicinal rashes — Gangrenous dermatitis. 

Eruptions with the formation of crusts and scales. 

Ichthyosis — Seborrhea — Impetigo contagiosa — Tinea fa- 
vosa — Tinea trichophytina — Psoriasis. 

Localized pruritus — Scabies — Pediculosis — Pigmentations of the 
skin — Nevi — Xeroderma pigmentosum — Eczema — Eczema 
rubrum — Seborrheic eczema — Intertrigo — Pustular eczema. 

Purpura — Purpura simplex — Purpura hemorrhagica — Henoch's 
purpura — Edema — Local — One arm — One leg — Feet — Face 
— Neck — Chest — Angic neurotic — General edema — Sclerema 
neonatorum — Anasarca — Myxedema. 

Scars and cicatrices. 

The veins — General venous distention — Local distention. 

Heat and moisture of the skin — Increased perspiration — Dimin- 
ished perspiration — General coldness — Local coldness — 
General heat — Local heat. 

Local swellings — Scleroderma — Furunculosis — Warts. 

Emphysema of the skin. 

Anemia 264 

Etiology — Simple anemia — Pernicious anemia — Leukemia — 
Chlorosis. 

Examination of the Heart 271 

Position of apex-beat — Displacements of apex-beat — Inspec- 
tion — Palpation — Percussion — Auscultation — Pericardial mur- 
mur — Acute pericarditis — Chronic pericarditis — Acute endocar- 
ditis — Apex murmur — Malignant endocarditis — Chronic valvu- 
lar disease — Mitral insufficiency — Mitral stenosis — Aortic ste- 
nosis — Aortic insufficiency — Tricuspid insufficiency — Tricuspid 
stenosis — Pulmonic stenosis — Pulmonic insufficiency — Func- 
tional murmur — Functional disease — Venous murmurs — Ane- 
mic murmurs — Congenital heart disease. 

The Pulse 288 

Rate — Increased frequency — Decreased frequency — Irregular. 

Urination 290 

Dysuria — Calculi — Balanitis — Urethritis — Vulvovaginitis — 
Erosions — Herpes — Frequent urination — Cystitis — Vesical 
spasm — Retention — Anuria — Scanty urine — Incontinence — 
Enuresis. 



CONTENTS 13 

PAGE 

Diseases in which the excretion is markedly diminished: 

Acute congestion of kidney — Chronic congestion — Acute 

degeneration — Acute diffuse nephritis. 
Diseases in which excretion is markedly increased : 

Chronic parenchymatous nephritis — Chronic interstitia 

nephritis — Diabetes insipidus. 

The Urine 301 

Color — Quantity — Specific gravity — Reaction — Urinary sedi- 
ments — Odor — Chemical examination — Albuminuria — Hemat- 
uria — Hemoglobinuria — Pyuria — Pyelitis — Tuberculosis of the 
kidney. 

Enlargement of the Scrotum . . . '. 309 

Hydrocele — Orchitis. 

Headache 312 

Acute headaches — -Toxic headache — Tuberculous meningitis — 
Purulent meningitis — Simple meningitis — Headache due to 
disease of organs of special sense — Chronic headache — Chronic 
headache due to disease of organs of special sense — Tumors of 
the brain — Cerebral abscess — Migraine — Neuralgia of supra-or- 
bital nerve. 

Paresthesia 320 

Vertigo 321 

Disturbances of Consciousness 323 

Diagnostic significance — Delirium. 

Convulsions 326 

General considerations — Convulsions in the newly born. 

Convulsions with fever and loss of consciousness. 

Febrile convulsions — Acute bacterial toxemia — Cerebral. 

Convulsions not associated with fever. 
Rachitic — Epilepsy — Hysteria. 

Convulsions without loss of consciousness. 

Tetany — Chorea — Habit — Athetosis and athetoid move- 
ments — Head-nodding — Rotary spasm — Nystagmus — Hic- 
cough — Congenital Myotonia — Torticollis — Laryngismus 
stridulus — Spasm of glottis — Tetanus — Strychnine pois- 
oning. 

Rigidity of the Neck Muscles 352 

Acute forms — Torticollis — Chronic forms. 

Paralysis 356 

General considerations — Types. 

Paralysis associated with flaccidity. 

Infantile spinal paralysis — Multiple neuritis — Transverse 
myelitis — Acute meningitis — Infantile cerebral paralysis 
(antenatal form)— Acute ascending paralysis — Diphtheri- 
tic — Choreic. 

Paralysis with associated spasticity. 

Infantile cerebral paralysis — Prenatal group — Natal group 
— Post-natal group— Acute acquired cerebral paralysis — 
Hereditary spastic paralysis — Transverse myelitis — Par- 
aplegia from spinal caries. 

Paralysis unclassified as to flaccidity, spasticity, or atrophy. 
Amaurotic family idiocy — Apparent paralysis from joint 
disease — Functional — Hysteric. 

Paralysis associated with marked atrophy. 

Muscular dystrophy — Peroneal form of muscular atrophy — 
Syringomyelia. 



14 CONTENTS 

PAGE 

Ataxia 392 

Hereditary ataxia. 

Pain 396 

Mode of onset — Time of occurrence — Character of — Site of — 
Diseases in which pain is the prominent symptom — Acute oti- 
tis — Gastralgia. 

Meningitis 402 

Pachymeningitis — Leptomeningitis — Tuberculous meningitis — 
Posterior basic meningitis — Acute suppurative meningitis — 
Epidemic cerebrospinal meningitis. 

The Temperature 413 

Chills — Fever — Symptoms of fever — Diagnostic significance — 
Causes of fever — Significance of type — Continued fever — Inter- 
mittent type — Remittent fever — Subnormal temperature. 

Enteric Fever 420 

Malaria 426 

Tuberculosis 431 

Scrofulosis 442 

Rachitis 444 

Hereditary Syphilis 450 

The Bones and the Joints 457 

Acute arthritis of infants — Infective ostitis — Acute osteomyeli- 
tis — Fractures — Osteopsathyrosis. 
Tuberculous diseases of the bones. 

Spinal caries — Pott's disease — Hip, Knee, Ankle, Elbow, 
Shoulder, Wrist, Sternoclavicular joint disease — Sacro-iliac 
disease — Tuberculous dactylitis. 
Syphilitic diseases of the bones. 

Acute epiphysitis — Chronic osteoperiostitis — Dactylitis. 

The Lymphatic Glands 477 

Acute enlargement — Chronic enlargement — Situation and 
drainage areas — Significance of localized tenderness and en- 
largement. 

The Acute Infectious Exanthemata 481 

General considerations — Rubeola — Rubella — Scarlet fever — 
Variola — Varicella. 

Diphtheria 513 

Rheumatism 522 

Cretinism 525 



Index 527 



DIAGNOSTICS 

OF THE 

DISEASES OF CHILDREN 



KERR 



DIAGNOSTICS 

OF THE 

DISEASES OF CHILDREN 



EXAMINATION 



The examination of children offers difficulties and peculiarities 
which are not patent in the adult. The greatest contrast to 
adult life is exhibited by the infant (by which we mean the child 
under two years of age). After the end of the second year the 
contrast becomes progressively less, until the end of the seventh 
year, when the child more closely approximates the adult than 
the infant. However, during all of this period, and continuing 
on to and through the period of adolescence, there are marked 
differences which relate particularly to etiology, pathology, symp- 
tomatology, diagnosis, and treatment. 

The idea that just as soon as a child is able to express its wants 
and feelings it becomes an adult in miniature is far from the truth. 
The child bears to the adult a relation of potentiality; nothing 
more. A complete description of all the changes in the econ- 
omy which mark the child as being distinctively different from 
the adult would include each element of mental and physical 
growth. Even a general recognition of these differences shows to 
one the error of applying exactly the same methods of diagnosis 
as obtain in the adult. 

There must be a thorough knowledge of the normal child at 
the different periods of its development and growth. Also an 
intimate knowledge of the morbid tendencies which are peculiar 
to each of such periods, and a clear understanding of the fact 
that from slightly active causes the child, with its unstable equi- 
librium, is very apt to exhibit the most varied and irregular dis- 
turbances. 

2 I 7 



1 8 EXAMINATION 

By far the greatest amount of information regarding the child 
is obtained by observation, so that the close study of symptoms 
must frequently displace the more exact measures of diagnosis 
which are useful in adult life. 

It is not only helpful, but it is important that the chief of the 
child's mental traits and powers be kept in mind, "so that advan- 
tage may be taken of these to secure at least a partial coopera- 
tion in the examination. The most noticeable power is that of 
attention. Not only is there the power of attention to direct 
itself toward any object which is presented, but there is often an 
inability to avoid doing so. The things which are going on about 
the little one command its attention, so that the child gives it in- 
stinctively without any effort of the will. This is true in part 
because curiosfty is so strong at this period of life. 

Activity is another of the more prominent traits of the child; 
it is naturally restless, not being willing to remain long in one 
position, and not being able to concentrate its mind long upon 
any one thing. The result of this activity often shows itself in 
what we call frivolity, the child delighting in constant change 
and play. 

At no time in life is imagination so vivid or intense as in early 
childhood. All the child's playthings are to its mind endowed 
with a certain amount of life and feeling. Two or three lines 
crudely drawn will be transformed by the child into an animal, 
house, or anything which the fancy of the one who draws them 
suggests. Advantage may be taken of this, for by using these 
strong imaginative powers the physician may secure a consider- 
able amount of cooperation by a few moments spent in tactful 
approach. 

Knowing that the child rebels against restraint, this must be 
avoided until all of the data possible have been secured. 

Subsequent examinations are easier if the affection of the child 
is won, for affection is very strong during childhood. 

The approach to the child should in most instances be very 
gradual, for the attendant must remember that he is dealing with 
an irrational, easily frightened being, whose disease has prob- 
ably irritated and exhausted it to such an extent that it lacks 
self-control. 



HISTORY OF PRESENT ILLNESS 1 9 

There are no hard and fast rules by which we may expect to 
win the child's confidence: one case requires to be absolutely 
ignored for the time being, while a history of the condition is being 
obtained; another must be approached at once. With a child 
of the latter class it is best that the physician retire at once at 
the first sign of rebellion at his presence, and obtain the full history 
of the case, after which the approach must be firm, to convince 
the child that you are master of the situation. 

The history of the present illness is naturally the first thing 
to be elicited, and this is best done by a leading question put 
to the parent, as, "Of what does the child complain?" (The 
ordinary question, "What is the matter with the child?" will 
usually meet with the response, "I do not know.") Only under 
exceptional circumstances should there be any interruption as 
the history is given. Full scope should be allowed to the parent 
to tell all about the child's condition, and meanwhile the physician 
should be studying two things: the history as given, and the 
temperament of the one who gives it. This latter is quite impor- 
tant, as there is a tendency in some to withhold knowledge of 
certain symptoms, or so to exaggerate particular ones that really 
important ones are overlooked. 

On the other hand, there are those who wilfully enlarge upon 
all the symptoms in order to excite the interest of the physician, 
or from some morbid tendency. The largest number deceive un- 
intentionally, through the habit of the loose and inaccurate use 
of words. 

In older children who show a normal degree of intelligence a 
few questions put to the child will be a valuable supplement to 
the history already obtained. 

The history obtained in the foregoing manner will, in nearlv 
every instance, be incomplete. Different methods cf elucidat- 
ing the history will suggest themselves, according to the tempera- 
ment and intelligence of the history-giver. The time spent in 
obtaining a full and complete account of the child's present and 
previous condition is never wasted. 

It is not necessary that the history be given in a concise way : 
the main thing is that the physician have in his own mind an 
orderly arrangement of the symptoms, in order to arrive at a 



20 EXAMINATION 

right conclusion as to further investigation. It may be necessary, 
in order to do this, to ask a few pointed questions. 

The statement as regards the time of onset will place the dis- 
ease in one of two categories — acute or chronic. Nevertheless, 
it is essential to learn, if the attack is acute, whether it is dependent 
upon some underlying chronic condition. From this, an endeavor 
should be made to arrange the subsequent symptoms in the order 
of their appearance up to the time of examination. If the child 
had been previously treated, completeness demands that the 
therapeutic measures used be known. 

What is the age? is a question the answer to which will largely 
influence the diagnosis. There are many diseases the frequency 
of which is determined by the child's age. Diseases of the new- 
born give evidence of their existence at birth, or within a few 
days of that event. This is true also of many injuries which are 
consequent upon the character of the labor. Included in these 
we observe caput succedaneum, cephalhematoma, hematoma of 
the sternocleidomastoid, visceral hemorrhage, obstetric paralysis, 
tetanus, asphyxia, atelectasis, ophthalmia neonatorum, etc. 

The occurrence of convulsions in a very young infant would 
have a far different meaning from, and lead us to a different con- 
clusion than, a similar condition in a child six or seven months 
old, and more still if it occurred after the third year. 

Undoubtedly the best illustration of this influence of age is 
afforded by icterus, a thing which in the new-born we disregard 
and look upon as physiological, but when it occurs in an older 
child is a very important symptom. 

During the first year of life diseases affecting the mucous mem- 
branes of the gastro-intestinal tract and nutrition largely predom- 
inate. 

From the sixth to the thirteenth month, and through the per- 
iod of weaning, there exists a tendency to affections of the mouth, 
eclampsia, and catarrhs of the large and small intestines. 

During the second year diseases show a marked preference 
for the mucous membranes of the respiratory tract, but the gastro- 
enteric diseases are still important factors. 

From the second to the sixth year the acute infectious diseases 
are common. After the third year catarrhal inflammations of 



PREVIOUS CONDITION 21 

the respiratory organs, tuberculosis, and diseases affecting the 
heart are most frequent. 

The previous condition of the child is the next step. Was 
the child full term or abortive? If the latter, there is quite suffi- 
cient reason for the child remaining weak and anemic for a long 
time. An abortive infant is also more liable to all the infec- 
tions, and shows a very marked tendency to become rachitic. 

Was the delivery of the child protracted? If so, it may account 
for a subsequent epilepsy or mental deficiency; or if difficult, but 
not necessarily protracted, for spastic hemiplegia and some other 
nervous diseases. 

How was the child fed? This question is of prime importance, 
and much care should be given to secure an answer, minute in its 
details, covering the whole period from birth to the present time. 
If breast-feeding was employed, it is essential to find out whether 
the infant was nursed by its mother or a wet-nurse. If by the 
latter, was there one or more who nursed the patient? 

In either case, what was the quality of the milk? Was the 
infant satisfied, and how long was it allowed to nurse, also at 
what intervals? Too long or too frequent feeding is a prolific 
cause of gastro-intestinal disturbances. Were one or both breasts 
used, and if both, were they used alternately? For the suckling 
of one breast twice in succession would greatly influence the 
quality of the milk withdrawn. 

The health of the nurse should be inquired into, also her diet, 
and whether she is menstruating or is pregnant. Periodical 
attacks of dyspepsia, with the consequent colic and restlessness, 
may depend upon menstruation in the nurse. 

With bottle-fed infants it is necessary to know accurately the 
source of the milk (can milk is not fit for infant feeding) ; also 
the strength of it, and with what the dilution was made. Dilu- 
ents containing any considerable amount of starch would be very 
apt to be harmful in infants under three months of age. 

As has already been stated under breast-feeding, the amount 
of food given at each nursing and the intervals between nursings 
are both very important. Nearly every infant, if left to itself, will 
overfeed, and almost every mother, unless instructed, will fall into 
the error of overfeeding the child. Herein is laid the foundation 



22 



EXAMINATION 



for diseases which appear later on. If there have been additions 
to the nursing (as the giving of thin soups, coffee, etc.), in just 
the proportion that they are given early, before the eighth month, 
will there be disturbances from them. 

The time of the eruption of the teeth should be gone into, espe- 





Fig. i. — The teeth between six and eight 
months. 



Fig. 2. — The teeth two months after the ap- 
pearance of the two lower central incisors. 



cially as to whether it was delayed (which is often the case in an 
infant poorly nourished although obese) ; and was the cutting of 
each tooth accompanied by any disturbance? Some difficulty 
will be here experienced, because the average mother will attrib- 
ute to the teeth all disturbances which occur during the time 
that the child should be teething. 



>"-**5^ 








Fig. 3.— The teeth between the twelfth and 
fourteenth months. 



4.— The teeth between the sixteenth and 
twenty-second months. 



Generally speaking, the deviation from the average in regard 
to teething is a fair indicator of the general nutrition of the infant. 
There may be normally a wide variation in the time of the appear- 
ance of the teeth in the infant, but there should be quite constant 



PREVIOUS CONDITION 



23 



regularity in the order of the appearance. The average order 
and time follows : 

Between six and eight months, the two lower central incisors. 

Two months later, four upper incisors. 

Four months after that, two lower lateral incisors and four 
anterior molars. 

Six months following, four canines. 

Another six months, four posterior molars. 

The average healthy child will be able to hold its head up 
steadily at the fourth month and will sit alone by the end of the 
ninth month. The child will walk between the twelfth and 
seventeenth months. It is important to learn if the child has 
walked and then ceased to do so. Unless this can be explained 
without doubt, it is strongly indicative of rachitis. 

If the child is one of several 




Fig. 5- 



-The teeth between the twenty-second 
and the twenty-eighth months. 



in the family, it is of some 
value to know the general phy- 
sical condition of its brothers 
and sisters, and in case some 
of them have died, the cause of 
such death should be learned. 
Where the family is a large 
one, inquiry ought to be made 
as to the time between the 
births, as rapidly recurring 

pregnancies not only debilitate the mother, but have a decided 
influence upon each succeeding child. 

A knowledge of the diseases from which the patient has pre- 
viously suffered is of much value, provided a fairly accurate 
account of their nature, date, and severity can be obtained. 
Previous attacks of certain diseases predispose to subsequent 
attacks. Among this group we find bronchitis, repeated convul 
sions, either infantile or epileptic, erysipelas, malaria, pneumonia, 
tonsillitis, and rheumatism. 

On the other hand, a previous attack renders a subsequent 
attack less probable in the following: rubeola, rotheln, scarlet 
fever, typhoid, variola, varicella, varioloid, and whooping cough. 

Certain other diseases arise as sequela\ so that a history of the 



24 EXAMINATION 

primary affection throws some light upon the present condition. 
Chief among these are otitis, renal disease and rheumatism fol- 
lowing scarlatina, skin eruptions, nervous affections, ulcers and 
periostitis from hereditary syphilis, and heart lesions in rheuma- 
tism (a most frequent occurrence). 



GENERAL POSTURE 

The position which a child assumes while in bed is quite often 
significant. The attitude of the child may, on the one hand, be 
reassuring, as we note that the little one rests easily and sits up 
or turns to greet the physician. It assures one that the ailment 
is slight, or that convalescence is well established. When the 
child refuses to notice or play, we may be sure that the illness is 
of a severer type. 

The side position is assumed characteristically in two dis- 
eases — acute pleurisy and pneumonia. In both cases the child 
lies upon the affected side so as to limit as much as possible motion 
of the diseased side and to allow free expansion of the unaffected. 
In pneumonia it is not difficult to get the child to change its posi- 
tion, but in pleurisy there is a decided objection to this procedure, 
which most often amounts to absolute refusal. 

If the child is pale and thin, indicating that the illness has been 
a long one, and the breathing is very much interfered with, we 
can be almost certain that there is a large exudate, and a light 
percussion would be sufficient to exclude pneumothorax. 

The dorsal position — (a) with slightly bent legs, is the position 
of election in cases of acute peritonitis and tubercular peritonitis. 
Motion is carefully avoided, and in acute peritonitis there is gen- 
erally evidence of fear as the child is approached. 

(b) With thighs and also the knees strongly flexed and more 
or less rigidity of the leg of the affected side the dorsal position 
occurs in perinephritis, but is a very late sign. The child may 
further be tested by the standing position, when the hand will 
be rested upon the knee of the affected side, or slightly above it, 
and the back will be slightly bent, with the concavity of the spine 
toward the affected side. 

(c) With a curve of the trunk slightly toward the right side 



GENERAL POSTURE 



25 



and with the right knee more or less flexed, or in some cases held 
up by the child, which gives relief to some extent, the dorsal posi- 
tion is assumed in appendicitis. 

(d) With the body held rigid, a strong disinclination to move 
at all, and the head elevated, the dorsal position occurs in peri- 
carditis. But pericarditis is a rare disease in young children. 

On the abdomen is the position taken in — (a) some cases of 
Pott's disease, but it is by no means characteristic ; (6) in phleg- 
mons of the back (to relieve the pressure) ; (c) and to eliminate 




Fig. 6.— Common posture of child with lumbar abscess or phlegmons of the back. 



the pain which is consequent upon much light in severe photo- 
phobia. 

Under forced positions it is only necessary to make mention 
of opisthotonos and emprosthotonos, which occur in some cases 
of tetany, strychnine poisoning, and meningitis. 

The upright or sitting position may assumed as the result 
of abdominal accumulations of fluid; from large effusions in the 
pericardial or pleural cavities ; and it attends some cases of laryn- 
geal diphtheria. 

FACIAL EXPRESSION 

The face of the average child expresses more clearly than does 
the adult the feelings and character of the individual. Except 
as the child more closely approximates the adult type, there is 
no attempt at deception by the facial expression. Siek or well, 
there is a candid frankness which allows of no exaggeration or 
dishonesty. 



26 EXAMINATION 

The value of facial expression as indicating diseased conditions 
will exist only as one appreciates what is normal; then, with the 
capability of comparison which comes by many observations, 
one can interpret the expression of the child. 

The normal expression of a child while asleep is one of per- 
fect unbroken calm and peace. The eyelids are closed, the lips 
very slightly parted, and the nostrils are immobile. 

Normal expression plus twitching of the facial muscles is 
indicative of irritation of some portion of the nervous system. 
It may be the forerunner which indicates an impending attack 
of general convulsions; but if so, there is very apt to be rest- 
lessness also. 

Normal expression with eyelids parted may be observed in 
many of the milder disorders of the nervous system and during 
digestive disturbances. If the muscles of the face are drawn 
from time to time, it strongly indicates that the disorder is a 
digestive one. 

Listlessness (that is, marked by a relaxed attention) may be 
due to several causes: (a) After some days' illness with typhoid 
fever a listless expression is an almost constant feature, (b) 
If associated with motionless or seldom moving eyelids, or with 
wide-open eyes staring steadily into the distance, it is quite indica- 
tive of meningitis, and this condition of the eyes and the expres- 
sion may help in some cases to differentiate it from typhoid, (c) 
With sunken eyes, and occurring at any time during any disease, 
it is a symptom of ill import, for it is then a sign of suddenly in- 
creasing prostration or impending death. 

Vacant Expression. — (a) Associated with enlarged head, but 
the bones of the face remaining small, and the eyeballs perhaps 
slightly protruding, is seen in hydrocephalus ; (b) with thickened 
lips, more or less gaping mouth, small nasal orifices, and a broad- 
ened root of the nose, is quite common in hypertrophied tonsils, 
and adenoids which are almost invariably associated with them. 

Idiotic. — (a) When the expression is idiotic and the lips thick- 
ened, the tongue protruding so that saliva is almost constantly 
dribbling from the mouth, the nose flattened, and the skin of a 
pallid, waxy hue, cretinism is probably the cause, (b) If the 
same picture is presented, but in a very much lessened degree, 



FACIAL EXPRESSION 



27 



we may be dealing with an exaggerated form of mental de- 
ficiency. 

Anxious Expression. — (a) With nostrils more or less dilated 
and labored breathing, the anxious expression is indicative of 
some disturbance to the circulation, and especially so if any cyano- 
sis is detectable. (6) This expression is present, with sunken 
eyes, depressed fontanelles, a general sharpening of all of the 
features, with the angles of the mouth drawn and considerable 
pallor of the face noticeable, in cholera infantum, (c) If the 
upper lip is retracted, exposing the teeth, and along with this 
there is visible prostration, it is indicative of acute peritonitis. 
(d) Associated with shallow respirations and increased frequency 
of breathing, and the cramped posi- 
tion on the side, it is presumptive 
evidence of acute pleurisy. 

Old Expression. — (a) With a 
pale, pinched, and weazened face, 
and associated with "snuffles" in 
an infant, it is indicative of heredi- 
tary syphilis. These infants look 
prematurely old and may also 
show a depression at the bridge of 
the nose and a prominent forehead. 
Such an expression is most apt to 
be noticed during the first two 
months of life. (6) When the skin 
has a leaden hue and is loose and 

wrinkled, one would naturally suspect marasmus. (c) An old 
expression is common to children of all ages, who are suffering 
or who have recently suffered from chronic starvation, and such an 
expression is quite in proportion to the chronicity of the condition. 

Expressionless. — This is usually due to the abolition of the 
distinctiveness of the features in advanced mitral disease. In 
edema and erysipelas all the lines of expression may be lost. 

Painful disfiguration of the face while pressure is being made 
over some distant portion of the body aids in definitely locating 
the site of tenderness, and sometimes of pain (pain may be 
referred). 




Fig. 7.— Facial expression in maras- 
mus. 



28 EXAMINATION 



The Face as Indicative of Disease 

The expression is an indicator of the psychical condition of the 
child under observation, and has at times a distinct value as an 
aid in diagnosis ; but, in addition to this, there are certain facies 
occurring during diseased conditions which are helpful in the 
recognition of such. Some of these facies are so characteristic 
that to one who understands them well they are a direct indica- 
tion as to the point at which the examination may begin. 

The facies of disease in childhood are not nearly so numerous 
as those which are encountered in adult life, so that I feel that 
it is best to describe them under the heading of the respective 
diseases in which they occur. 

Nephritis. —The face is pale and puffy if edema is an accom- 
paniment. The paleness is not that of simple anemia, but there 
is more of a waxy hue. The intelligence of the expression is apt 
to be diminished. 

Pertussis. — The face is puffy and pale, as a rule, and it closely 
simulates the face of nephritis, but the paleness is more of the 
anemic type, and added to this is more or less suffusion of the 
eyes. Frequently the eyeballs are much injected, or may be 
the site of minute hemorrhages. 

Hereditary Syphilis. — When syphilis is fairly well developed, 
the infant has a pitifully old, weazened look. The skin is dusky, 
yellowish, or wrinkled, and the infant suffers from persistent 
snuffles. Later the nose may become flattened and broadened. 
If such a facies is present in an infant a few weeks old, it is almost 
positive evidence of syphilis, and examination will usually con- 
firm the suspicion, as other signs are found. 

Tubercular Bone Disease. — In this the features of the child 
are very coarse and heavy. Usually the child is stocky, with a 
short and thick neck. 

Chronic Malaria. — In this disease there is more or less pallor 
of the face, sallowness, and frequently a slight degree of puffiness, 
all of which would probably create a suspicion of renal disease. 
With a negative urinalysis the next thought should be of chronic 
malaria. 

Mouth-breathers are a type in themselves, indicating some 



TH^ body weight 



29 



interference with normal breathing through the nose. Such 
children have a vacant expression and hold the mouth more or 
less widely open. The expression of the eyes is dull and the eye- 
lids are apt to droop. The lips are thickened and the nasal ori- 
fices smaller than normal, while the root of the nose may be 
broadened. All this, with 
the rounded shoulders 
and the general sluggish 
appearance of the child, 
gives a picture which is 
quite characteristic. 

Cretinism. — This 
gives a particularly char- 
acteristic appearance. 
The head, in the first 
place, seems too large for 
the dwarfed body. The 
forehead is low with a 
very much broadened 
base of the nose, so that 
the eyes are widely sep- 
arated. The lips are 
very much thickened 
and the mouth is open, 
with the tongue protruding slightly. Saliva dribbles more or 
less freely from the mouth. The cheeks are baggy and loose 
and the hair coarse and straight. The fontanelles remain open 
sometimes until the tenth year, or even much later. 




Fig. 



-Facial expression of a mouth-breather. 



THE BODY WEIGHT 

An intimate acquaintance with the weight of the infant in 
its different periods of development is of far more importance 
than a similar knowledge of the adult. The body weight is the 
most valuable guide which we possess as an indicator of the gen- 
eral state of nutrition. It would be hardly possible to over 
estimate its importance during the first two years of the child's 
life. 

Gain in weight is, however, not the onlv factor to be considered. 



3Q 



EXAMINATION 



but one must know what is the normal average for different pe- 
riods, and comparison must be made with these. A fat baby is 
not necessarily a healthy baby (the laity to the contrary), for 
too rapid gain in weight may be the result of faulty nutrition. 

The average weight at birth is close to seven and one-half 
pounds. If the new-born infant weighs less than five and one- 
half pounds, it is presumptive evidence that we are dealing with 
an underdeveloped child. Such infants are rarely healthy or 
vigorous, and although they may appear so at first, within a few 



DAILY WEIGHT CHART, 
Name, Date of Birth, 1 9° 


Gms. 


Lbs. 


1 


2 


3 


i 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


IS 


10 


17 


18 


19 


20 


mo 

4310 
4200 
4080 
3970 
3850 
3740 
3630 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 


9% 
9V 2 

*U 
9 

%% 

s% 

8 

7M 

7 

6% 

6K 

6 

5& 
5% 
5K 






































































































































































































































































































































































i 


















































































\ 





































































































































































































































































































































































Fig. 9.— Weight curve of the first twenty days (Holt). 

days they show that they are difficult to nourish and their resist- 
ing powers are very low. 

During the first three or four days after birth there occurs a loss 
in the infant's weight which is normal. Approximately, it amounts 
to one-tenth of the original body weight. By the end of the tenth 
day, at least, this loss should have been regained and the infant 
be at its original weight. From this time on the gain should be 
progressive and steady, and this can be determined only by more 
or less frequent weighings. 



THE BODY WEIGHT 



31 



A word in regard to the gain in weight of infants who are under- 
weight at birth : these little ones do not reach their original body 
weight, after the loss of the first four days, until the end of the 
second or even the end of the third week. 

There should be no difference in the gain in weight between 
the breast-fed and the artificially fed infant. In practice there 
will be a very noticeable difference at times, but this is due to 



WEIGHT CHART. 
Name, _ Date of Birth, 190 


£ 


CO 

_! 


MONTH OF AGE. 


123456 78 9 10 11 12 


10890 
10430 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
S630 
3180 
2720 
2270 


24 
23 
22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
G 
5 




































1 
























































1 
























































1 


































































































































































































































































































































































































































































































































































































',* 














































































































































































































































































































































































































































































































































s' 






















































s 










































































































/ 






















































/ 














































































































/ 






















































/ 














































































































/ 






















































/ 
























































y 






















































/ 






















































te 


/ 


































































































































































































































































































































l ! 



Fig. 10.— The weight curve of the first year (Holt). 



faulty nutrition, and when such a difference is observed, its cause 
should be sought for and remedied at once. 

The accompanying chart (Fig. 9) represents the variations in 
weight for the first twenty days of life. The curve shows a very 
decided loss upon the first day and a lesser one on the second. 
The lowest point was reached on the third da v. From this on 
there is noticed a steady gain. The loss occurring- during the first 
days is due to the discharge from the bodv of the meconium 



32 EXAMINATION 

and the urine, and also to the excess of tissue waste over the 
nutriment derived from nursing. 

Both these weight charts are from Holt, and they represent 
what is the average for a large number of children. Neither 
must be considered as representing what the infant must weigh 
to be normal ; normal gain would be for the little one to increase 
in proportion, which necessitates knowing the birth weight. 

During the first year of life the greatest gain takes place dur- 
ing the first three months, and is slowest from the sixth to the 
ninth month. From the beginning of the second until the fifth 
year the gain is approximately as follows: During the second 
year, six pounds ; during the third year, four and one-half pounds ; 
during the fourth year, four pounds. 

During all this period, except the second year, the gain is 
not steady, varying considerably with the seasons, being less in 
the heated term. 

Loss of Weight 

Loss of weight in the child may be gradual, rapid, or relative, 
and the distinction of the various types is very important. By 
relative loss of weight I mean that the gain is below what it should 
be in the normal infant; the infant gains, but not so much as 
it ought to, to constitute a healthy condition. 

Unfortunately, many times we have to rely upon the statements 
of a parent who is careless in regard to these matters, or who 
disregards their importance wilfully or through ignorance. For- 
tunate we are if the opportunity has been ours to watch the 
development of the infant, or if weighings have been taken at 
stated intervals. 

Gradual loss of weight in infancy is the result in most instances 
of chronic starvation. This may, in turn, be due to one or more 
of several factors: either the food is not sufficient in quantity, 
it is poor in quality, or it may be unadapted to the age and the 
strength of the infant. 

There is also a form of chronic starvation which might be called 
"symptomatic," as it is an accompaniment of many other diseases, 
especially intestinal catarrh. This form may appear at any time 
of life, but usually it does not show itself until after the fourth 



THK BODY WEIGHT 33 

month. The diagnosis is made by considering the disease dur- 
ing the course of which it develops and by exclusion of all other 
causes. 

Several days may be spent in determining satisfactorily that 
a steady loss is not due to tuberculosis. During this time several 
physical examinations may be necessary and the temperature 
should be watched over a considerable period. The absence of 
cough in no way influences the diagnosis of tuberculosis. The 
family history and a history of the surroundings of the infant are 
both most important. 

Relative loss of weight is very common in infancy. The gam 
may be very slow, the muscular development and growth tardy, 
and the powers of digestion and resistance considerably enfee- 
bled. Such infants may be the offspring of delicate or nervously 
exhausted parents, but more often they are the direct product 




Fig. 11.— Marasmus— infant of five months. 

of a parent's foolish care, being housed in close quarters or over- 
heated rooms and having a deficient supply of fresh air. The 
characteristic thing about such infants is that all their growth 
is slow. This constitutes that class of infants who are suffering: 
from malnutrition. In most instances the fault is not one of 
nutrition, pure and simple, but one of poor hygiene. 

A very large proportion give an indefinite history of failure to 
keep up to standard, lasting over a somewhat extended period. 
until the constitution gets into such a condition that the slightest 
causes result in disease. It is almost impossible to determine with 
any accuracy when this state of malnutrition ends and its usual 
successor, marasmus, begins. 
3 



34 EXAMINATION 

Steady loss is by far the most constant feature of marasmus. 
The general appearance of such infants is characteristic : the skin 
is wrinkled and lacks its normal tone, hanging in folds upon the 
extremities. The child has the look of an old person. The 
abdomen is prominent, the eyes large and with an appealing 
expression, and all the features are sharpened. There is apt to 
be a hollowing out over the temples, and the legs and arms are 
justly likened to drumsticks. 

Anemia is a constant feature of these cases and is generally 
present to a considerable degree. The temperature is usually 
subnormal. Under causes so slight that it hardly seems possible, 
vomiting and diarrhea are induced. The course of the disease 
is steadily worse. 




Fig. 12. — Marasmus — infant of five months. 

The differentiation of marasmus from tuberculosis is sometimes 
very difficult, and in a few cases it is impossible during life. Poste- 
rior auscultation has no differential value, for hypostatic pneu- 
monia, which frequently occurs during marasmus, gives no signs 
which are definitely distinguishable from tuberculosis. Ante- 
rior auscultation and percussion are of much more value, for if 
signs are found there, they are more indicative of tuberculosis 
than of any condition which occurs in the course of marasmus. 
This is especially true if consolidation is present. 

The previous histories of the cases are of much value. The 
tubercular infant is generally delicate from the time of birth; 
in marasmus there is almost uniformly a history of healthy early 
infancy, which continued until some necessity arose for wean- 



THK BODY WEIGHT 35 

ing or for changing the food. This change has usually taken 
place some time during the first six months of life, and from that 
time the trouble began. 

Rapid loss of weight is preceded in nearly all instances by 
malnutrition, but it may require some care to bring out this fact. 
Following out in minute detail the history of the child's develop- 
ment, we find that the little one "has not done well " for some 
time past. Then more or less severe symptoms appear suddenly ; 
the loss in weight is now very rapid (three or four ounces in one 
day), and the temperature may be subnormal. When little or 
no food is taken or retained, the temperature may be quite high 
and a fatal result ensue within three or four days. The pulse is 
always weak and rapid, and evidences of considerable prostration 
are not wanting. There is usually marked pallor, and at times 
cyanosis. 

In young infants there is the probability of mistaking this 
condition for some other disease (especially pneumonia, menin- 
gitis, or gastro-enteritis) , unless we remember that following mal- 
nutrition we frequently observe this foregoing chain of symp- 
toms, which is strong presumptive evidence of the disease with 
which we are really dealing — acute inanition. 

Acute inanition is a condition which is induced by a lack of 
assimilation. Many of the symptoms which are observed during 
the course of the acute digestive diseases are due to inanition, 
but here we consider it independently of such relation. 

There may be continued fretfulness with crying, or a state 
of semi-stupor may persist, but from this latter the infant is 
easily aroused. Whatever is taken in the form of nourish- 
ment seems to pass through the body unchanged. There is 
little desire for food, but it may be taken for several feedings 
and retained for a long time, when the whole amount may 
be vomited. The younger the infant, the more likely this is 
to occur. 

As distinguished from malnutrition and marasmus, acute in- 
anition is much more acute, and is rare after the child has passed 
the fourth month of life. 

Stationary weight should at once lead to an investigation of 
the child's nutrition, and one must not be satisfied that the nutri- 



36 EXAMINATION 

tive processes are not at fault until the most searching examina- 
tion has been made to eliminate such a fault. 

During any of the acute illnesses there may be stationary 
weight, but when the acute symptoms are passed, the gain is 
again evident. During the convalescence from an attack of 
ileocolitis occurring in the summer months a child is very apt to 
exhibit stationary weight. The more the child eats, the less it 
seems to improve. The cause is usually found in a chronic 
ileocolitis of a mild type. In catarrh of the stomach and in 
chronic intestinal indigestion, the weight remains stationary, 
as a rule. 

Rapid gain is observed in cretinism, general anasarca, and 
sarcoma of the kidney, but other distinctive signs of these dis- 
eases are present earlier than the rapid gain, so that they are 
recognized. 

SLEEP 

The tired organism demands a period of physiological rest 
during which there can be repair to the fatigue changes which 
are consequent upon physiological cell activity, and this rest is 
called sleep. This repose is absolutely essential for the vital 
activity of cells. 

Normal sleep has as its constant features loss of consciousness, 
loss of voluntary inhibitory control of mental and motor acts, 
and more or less loss of all of the special senses. Normally, 
during the first hour sleep becomes more and more profound, 
but during the second hour there is lessened profundity, and 
thereafter it does not require a very strong stimulus to arouse 
the individual. 

The healthy new-born infant sleeps nearly all of the twenty- 
four hours. During these first few days the sleep is heavy, 
because the organs for receiving and carrying peripheral stimuli 
to the central nervous system are underdeveloped. During 
the first month the normal infant sleeps about twenty hours and 
sleep is less profound during the latter two weeks than at first. 
From the end of the first month slightly less sleep is required, so 
that at six or seven months the average time spent in sleep is six- 
teen hours. Between the end of the third month and the begin- 



ning of the third year sleep is noticeably profound during the 
first two hours. At the age of one year the child sleeps about 
twelve hours out of the twenty-four. 

Disturbed sleep (that is, waking frequently) is usually due 
to a general nervous irritability, which may be hereditary or 
depend upon malnutrition. This irritable condition is exagger- 
ated by excitement. Faults of training may be responsible. In 
a large proportion of instances in infants the cause of disturbed 
sleep is hunger. (The quantity of the food may be sufficient, 
but the quality poor.) Indigestion is the next most frequent 
cause, and in later childhood fully half the cases of disturbed 
sleep are dependent upon it. Overheated or poorly ventilated 
rooms and uncomfortable bed-coverings may be its cause. When 
disturbed sleep has as its accompaniment the so-called darting 
pains, it is quite indicative of hip-joint disease; in fact, it may 
be the first thing to attract attention to the existence of that 
disease. 

Restless sleep is evidenced by the child frequently changing 
its position, but without awaking. In a child free from disease 
it is evidence of an irritable nervous system. It is a feature of 
all malnutritions, but is most marked in marasmus. Associated 
with inability to lie upon the back for any length of time it is some- 
what characteristic of nasal obstruction or adenoid disease. 

Uneasy sleep (when the child is restless and easily aroused) 
is frequently caused by indigestion, slightly painful conditions, 
or intestinal parasites. In children of all ages the possibility 
of insect bites must be recalled, and no hesitancy should be shown 
to have a search made to clear up any doubt upon this matter. 
The sleep of the anemic child is always uneasy. Fever may 
account for either restless, disturbed, or uneasy sleep. 

Night Terrors. — This is a neurosis depending upon an abnor- 
mally irritable nervous system, easily excited by reflex stimuli 
in remote parts of the body. The child wakes suddenly with 
violent screaming and gives evidence of great terror. This may 
be repeated night after night. Such terrors take on the form of 
epileptic seizures and should be differentiated from them. Hexed 
ity plays an important role as an etiological factor, the particular 
defect which is inherited beins: a feeble inhibitory control of men- 



38 EXAMINATION 

tal and motor acts. Malnutrition is an important factor in 
developing irritability, therefore its common causes — as lymph- 
node tuberculosis, chronic diseases of the gastro-intestinal tract, 
rachitis, chronic malaria, improper food, impure air, and bad 
hygiene — may be important predisposing factors. Mental excite- 
ment or overwork associated with physical debility may be at 
the root of the trouble. 

After this state of nerve irritability is once established, it 
requires but a slight active cause to bring about the attacks. 
Disorders of the intestinal tract are the most important of these 
reflex factors, but in many instances reflex factors may be so 
slight as to be undiscoverable. 

Incontinence of urine may occur during an attack, or, as 
frequently happens, the child may make known its wants in this 
direction, and have evacuations of both bladder and the bowel, 
without giving any other evidence of being conscious of its sur- 
roundings, and having no recollection of the occurrence later on. 
In the presence of such attacks one must be guarded in deciding 
that epilepsy is not present. 

Another type of night terrors is that in which the paroxysm 
is less severe, and the child becomes quickly conscious of all 
his surroundings, and has* a more or less vivid recollection of all 
that has occurred. 

Excessive sleep is almost invariably due to the ingestion of 
some narcotic drug, given knowingly, or more often ignorantly. 
Usually there is the history of the ingestion of a cough mixture 
or soothing syrup, which will help in the diagnosis. If drug 
ingestion can be absolutely excluded as the cause, we are justi- 
fied in suspecting some organic brain lesion. 

Drowsiness coming on during the daytime and associated with 
a disinclination to play, or to remain normally active, may be 
due to the onset of one of the febrile diseases. If there is added 
a change in the disposition of the child, it is strongly indicative 
of the development of tubercular meningitis. Occurring peri- 
odically, it may be the first thing to arouse a suspicion of malaria. 

Somnambulism is a disorder of sleep whose etiological factors 
are almost identical with those of night terrors. While such a 
state is not uncommon to childhood, anything more than the 



SLEEP 39 

simplest movements are very infrequent. The child may walk 
or even run about the room, but rarely does more than this, 
and when aroused, is perfectly unconscious of anything which 
has happened. Frequently sleep-talking is associated with sleep- 
walking. 



THE HEAD 

Examination of the child's head is made by the usual methods 
of inspection, palpation, and measurement. 

Shape. — The infant's head at birth may be misshapen or 
asymmetrical, as a result of the conditions existing at the time 
of labor. The usual deformity is an elongation (and a further 
modification may come from caput succedaneum), which usually 
rights itself by the end of the first week. Considered as a whole, 
the large preponderance of cranial over facial proportions is 
marked. The parietal eminences are large. 

By the end of the first month the head should have assumed 
an oval and symmetrical shape. Later in life than the end of the 
first month any change in the shape of the child's head is not 
normal. The shape of the rachitic head is quite characteristic: 
viewed from above, the cranium is elongated, large, and square. 
The vertex and the occiput are flattened; the frontal eminences 
protrude and the fontanelle is open longer than normal. 

In sporadic cretinism the head is also flattened at the top and 
the fontanelle open, but the whole head is enlarged to a consider- 
able degree. The face is broad and the nose is like that of a 
negro, the forehead low and the eyes widely separated. 

The head of the child with hydrocephalus is very large and the 
shape is either globular or pyramidal, the forehead being very 
prominent about the root of the nose. 

Asymmetry of the head, if slight, may be due to one of two 
causes : (a) The habit which some infants are allowed to get into, 
of lying quite constantly upon one side (and that the same one), 
causes asymmetry by pressure, (b) It may occur in consequence 
of hemiplegia. 

More marked degrees of asymmetry usually depend upon the 
early ossification of the sutures upon the affected side. More 
rarely it is due to an underdevelopment of the hemisphere. 

The size of the head is best determined by a comparison with 

40 



SIZE OF HEAD 



41 



the size of the chest, for the two are almost similar in measure- 
ment. Until the end of the fifth month of life the circumference 
of the head is about one-half inch larger than that of the chest. 
From the sixth month until the eighteenth month they even 
more closely correspond, so that there is normally only a frac- 
tion of an inch in difference. After the eighteenth month, and 
until well along into the fifth year, the chest measurement pro- 




a b c 

Fig. 15. 
Figs. 13, 14, and 15.— Comparative cranial contours: a, Anteroposterior; £, circumference ; 
c, transverse. Fig. 13, Microcephalic. Fig. 14, Hydrocephalic. Fig. 15, Rachitic. 



gressively and proportionately increases over that of the head, 
until at the sixth year of life it exceeds it by one inch. 

Such figures as these, of course, can only be taken as an average. 
but a difference at any time of two inches or more between the 
chest and head measurements should lead to an investigation for 
the cause . 

Gradual enlargement of the head is, in the large majority of 



42 



THE HEAD 



cases, due to rachitis. The increase in size is quite slow, and 
usually very irregular also, and this latter (irregularity) is of con- 
siderable diagnostic import. The greatest source of error is in 
mistaking early cretinism for rachitic enlargement of the head, 
but the general torpor which is so evident, the facial expression, 
and the temperature should help to distinguish the former. 

In hypertrophy of the brain the development of the enlarge- 
ment is exceedingly slow ; so slow, in fact, that it is scarcely notice- 
able, even over a protracted period. 

Rapid enlargement is by far the most constant and character- 
istic feature of hydrocephalus. If the enlargement of the head is 

one inch or over in one 
month, from that fact 
alone one can almost 
certainly make a diag- 
nosis. In a few in- 
^j||^ "~~"* ill ^BS [ stances hydrocephalus 

I *,-v may exist without any 

appreciable enlarge- 
ment of the head, for 
such enlargement may 
be prevented by the 
early ossification of the 
sutures and. bones of 
the skull. Early death 
occurs in these cases, 
because of the pressure 
within the skull. 
Small size of the head is determined in infancy, if the chest 
measurement exceeds that of the head very much, during the first 
year of life in particular. It constitutes the condition called 
microcephalus, and is indicative of future mental deficiency or even 
idiocy. 

Baldness of the occiput is strongly indicative of rachitis. The 
hair of the rest of the head may be quite abundant, but at this 
point it looks as if it had worn off. 

Sweating of the head is an early and a very suggestive symptom 
of all forms of malnutrition, and especially of rachitis. Fre- 




Fig. 16.— Measuring the head. 



THE FONTANELLES 43 

quently, over a long period, it is the on'y symptom of a fault in 
the nutritive processes. It readily explains why some infants 
suffer so frequently from coryza. Head sweating is particularly 
liable to occur during sleep. 



THE FONTANELLES 

At birth, and existing for some time after that event, there are at 
the angles of the parietal bones membranous spaces, which are the 
fontanelles. The most important and largest of these is the an- 
terior median (commonly designated as the anterior fontanelle), 
which is situated at the junction of the frontal, sagittal, and coronal 
sutures. Immediately after birth this fontanelle is slightly de- 
pressed. It is quadrilateral, and there is pulsation which is 
correspondent with the pulse frequency. 

The posterior median fontanelle (posterior fontanelle) is smaller 
than the anterior and is triangular in shape. The other four 
spaces are at the inferior angles of the parietal bones and are ir- 
regular in shape. The only ones with which we can be concerned 
in diagnosis are the anterior and the posterior. 

The size of the anterior fontanelle apparently increases during 
the first six months, owing to the rapid growth of the head during 
that period, but toward the end of the first year there is a dis- 
tinct diminution in size, and ossification is usually complete by the 
middle of the second year. If at any time during infancy the dis- 
tance between the opposite sides of the anterior fontanelle is over 
one inch, it should be considered pathological. The sutures begin 
to unite about the ninth month, so that considerable firmness is 
detectable. 

The posterior fontanelle closes at the second month of life, as a 
rule, and is subject to so little variation in this regard that if at 
the end of the second month it is still open, it is indicative of some 
nutritive fault. The closure of the anterior fontanelle may be 
normally subject to wider variation; to wit, as late as the twenty- 
second month. 

Delayed closure of the fontanelle is generally due to deficient 
or delayed ossification, which is the result of malnutrition. Of all 
the nutritive disturbances, rachitis is most likely to cause it, and 



44 TH 3 HEAD 

during the first year this may be the chief symptom which we 
encounter. The constancy with which this condition exists in 
rachitis is an important factor in its exclusion. 

Hydrocephalus causes pressure from within, and in that way 
interferes with the normal closure of the fontanelle, provided the 
disease begins before there has been any considerable ossification ; 
otherwise the pressure does not interfere with complete closure 
and the infant dies early from the pressure. 

Slightly bulging fontanelle may occur during the continuance 
of any considerable elevation of temperature, no matter what 
the cause. It has no diagnostic value, unless it occurs in an infant 
in whom one would expect to find a sunken condition of the 
fontanelle (see below), in which case its significance would corre- 
spond with that of an intense bulging fontanelle (see the follow- 
ing). 

Tense and bulging fontanelle is due to an increase of pressure 
within the cavity of the skull. It may depend upon the existence 
of hydrocephalus, but there is only one way to determine this 
point absolutely, and that is by measurement. 

If in addition to the tension and the bulging there are unmis- 
takable evidences of suppuration going on, one is led to suspect 
the last stage of cerebral abscess, or, more commonly, purulent 
meningitis. Before the occurrence of this event, in the course 
of either of these diseases, the diagnosis may usually be made. 
Sometimes, however, abscess and meningitis are associated 
and a diagnosis has been difficult ; then the more marked the cere- 
bral symptoms and the neuritis, the greater is the probability of 
abscess. 

In the newly born infant a tense, bulging fontanelle, with 
entire absence of all pulsation, is indicative of meningeal hemor- 
rhage. The same would also hold true if the bulging was present 
without much tension, for the normal condition at this time is 
one of slight depression. 

Sunken fontanelle is not of itself indicative of anything. 
However, accompanied by other signs, it may be part of the 
general picture observed in many cases of collapse. If the bones 
of the skull allow their edges to slide easily over each other, and 



CRANIOTABKS 45 

with this there is sunken fontanelle, it suggests two conditions 
■ — either simple atrophy or hydrocephaloid. 

Murmuring. — If upon auscultation of the fontanelle a murmur 
can distinctly be heard, and that murmur is synchronous with 
the pulse, it is in nearly every instance due to anemia, and the 
fact that it occurs not uncommonly during rachitis is due to the 
fact that anemia is one of the features. 



CRANIOTABES 

Craniotabes are soft spots which appear in the occiput (common 
form), or may be a general softening of the whole bone without 
definite soft spots. The type accords with the severity of the 
cause, the spotted being the milder type. The cause is always 
one of two — rachitis or syphilis. The simplest and safest way to 
demonstrate them so that they will not be overlooked is to stand 
at the side of the recumbent child, facing it ; then with the thumbs 
resting upon the forehead the bent fingers of both hands are 
swept over the whole of the occiput. Upon pressure the feel is 
as though parchment was being crushed. 

In very rare instances they are present at birth, but disappear 
rapidly. The acquired form usually appears about the fourth 
month of life. 



TUMORS OF THE HEAD 

Tumors of the head occur with most frequency in the newly 
born infant. 

Caput Succedaneum. — So common as almost to rank as a 
physiological process is the formation of a diffuse tumor of the 
head, appearing at or shortly following delivery. Such a tumor 
occupies the portion of the head which has been subject to the 
greatest or most prolonged pressure. It is doughy in its consist- 
ency and sufficiently edematous to pit slightly upon pressure. 
The margins are not clearly defined, there is absolutely no con- 
nection with any of the sutures, and the whole mass is of a bluish 
color. The skin covering the tumor may be bruised, and this is 
the one thing which adds to the importance of the tumor the 



46 The: head 

possibility of infection. This eliminated, the tumor has no 
importance and the fluid content is usually absorbed within four 
days. 

Cephalhematoma differs from the former by appearing two 
or three days after delivery. This tumor may be due to extravasa- 
tion external to the skull, or the blood may be connected with 
an accumulation within the cranium. Although it is generally 
stated that it arises from the same causes as caput succedaneum, 
this is not true, for it is sometimes present in breech cases and in 
infants delivered by Cesarean section. 

At first there may be a rather rapid increase in the size, then 
follows a period of quiescence lasting for several days, and finally 
a gradual subsidence, with complete disappearance within four to 
twelve weeks. To the touch the tumor is soft, elastic, and 
fluctuating. There may be double or even triple tumors. 

The tumor is invariably limited in its extent by the borders 
of the bone over which it occurs; it is characteristic of it that it 
never crosses a suture. This very fact would differentiate it 
from a hernia cerebri, which always comes through at an opening 
or unprotected space. 

The skin over a cephalhematoma is normal; and this helps 
to distinguish it from caput succedaneum, which is covered with 
bluish skin, crosses sutures and fontanelles, pits on pressure, and 
disappears early. 

Meningocele, Encephalocele, Hydrencephalocele. — In com- 
mon, all of these tumors have a smooth or lobulated surface and 
are protrusions of a portion of the cranial content through an 
opening in the skull. The first is a protrusion of a portion of the 
membranes of the brain; the second contains a portion of the 
brain substance; while the third contains brain substance and 
cerebrospinal fluid. 

Meningocele is the rarest form of the three. The tumor is 
small at first, but increases in size; it is pediculated and has a 
smooth surface. Fluctuation is usually very distinct. 

Encephalocele is usually small, rarely pediculated, and never has 
fluctuation as a feature, but there is distinct pulsation. 

Hydrencephalocele is large and pendulous with a lobulated. 
surface. 



TUMORS OF THE HEAD 47 

Pneumatocele Cranii. — A remarkable form of tumor is occa- 
sionally met with in infants. It is tense, well denned, and pain- 
less, and can be reduced by pressure. Usually it is congenital, 
but may appear in later life and without apparent cause. The 
usual situation is over the temporal bone. Strong expiratory 
efforts increase the size of the tumor. Puncture allows the 
escape of air, but the tumor soon refills. 



EXAMINATION OF THE NOSE 

The examination of the nose and the adjacent structures and 
cavities in the infant does not differ in any material way from a 
similar examination in the adult. In very young children there 
is a lack of cooperation which makes such an examination 
impossible or very unsatisfactory. 

Pain about the Region of the Nose. — This may be described 
by an older child as of a smarting or burning character, and when 
located in the nose, is generally due to some acute catarrhal 
inflammation. In other instances it may be due to the impac- 
tion of a foreign body or to ulceration. When pain is more or 
less severe and referred to the parts just about the root of the nose, 
it is usually due to trouble in the frontal sinus. If pain is referred 
to the cheek or in the nose, and catarrhal inflammation is ex- 
cluded in the nose, then it is suggestive of some affection of the 
antrum; if referred to the ear, it may be due to affection of the 
eustachian tubes, but all possibility of an ear affection must be 
excluded (a very difficult matter). The only safe way to diagnose 
a eustachian-tube disease is to observe the symptoms as they 
follow or are associated with disease of the nose. 

Nasal Stenosis. — There is a difficulty in breathing through 
the nose in acute rhinitis, diphtheria of the nasal passages, when 
foreign bodies have been introduced (usually limited to one side), 
and in asthma. In all these the difficulty is of rapid develop- 
ment. When more gradually developed, nasal obstruction may 
be due to chronic rhinitis, growths within the nasal cavity, deviated 
septum, or syphilis. 

Discharges from the Nose. — Discharges from the nose may 
be watery mucous, muco-purulent, or purulent, and without 
offensive odor; or the secretion may be offensive or bloody. 
However, for the purposes of diagnosis the best division is into 
acute and chronic discharges. 

4 8 



ACUTE NASAL DISCHARGE 49 

ACUTE NASAL DISCHARGE 

Acute Rhinitis. — Rhinitis, whether acute or chronic, is one 
of the commonest disorders of early life. There are several 
predisposing causes which make the child particularly susceptible 
to it. Five such factors are more or less in evidence : 

(a) The age: the younger the child, the less active need be the 
exciting cause of rhinitis. 

(b) Lowered vitality, especially if dependent upon nutritional 
defect. 

(c) Hereditary influences, including malformations of the nose. 

(d) The presence of pathogenic bacteria. 

(e) Exposure to atmospheric change, which is the least impor- 
tant of all the factors. 

The disease in the acute form usually begins with an attack of 
sneezing, which is gradually followed by a sense of stuffiness in the 
head and a peculiar dry and irritable condition of the mucous 
membrane of the nose. Within a few hours there appears a 
profuse watery discharge, which, as a rule, is very irritating, 
producing redness or excoriation at the edge of the nostril and 
upon the skin over the lip. This may be followed by a muco- 
purulent discharge, some interference with the senses of smell 
and taste, and slight fever. Frequently the occlusion of the nasal 
passages is such that mouth-breathing becomes a necessity, 
resulting in a distressing dryness of the throat. This may lead 
to a secondary pharyngitis and laryngitis. 

In nurslings the first evidence of the disease is usually given 
by the child attempting to nurse, leaving the breast with a cry, 
and immediately returning to the breast, only to have the same 
performance repeated all over again. This is occasioned by the 
fact that the occlusion of the nose interferes with free nursing 
and the child rebels. 

The duration of the disease is from a few days to three weeks. 

The diagnosis presents practically no difficulty. Where the 
difficulty is experienced is in assigning the cause. Especially 
inclined to attacks of acute rhinitis are those children who are 
brought up like hot-house plants, being more or less confined in 
overheated rooms. When a history is obtainable, as is most 
4 



50 



EXAMINATION OF THE NOSE 



frequently the case, it is that the child takes cold easily and that 
it always affects the nose, and under such conditions we are 
justified in suspecting that a chronic rhinitis exists, and that the 
acute attack is merely an exacerbation. It is very unusual to see 
the case so early that there is not some chronicity about the 
disease. 

An acute rhinitis occurring in an infant a few days old, with a 
nasal discharge which is purulent from the start, should at once 
arouse a suspicion of gonorrheal infection. If, associated with 
it, there is a blennorrhagic conjunctivitis, the diagnosis is prac- 
tically certain; but in the case of a reasonable doubt, recourse 
may be had to microscopic examination of the discharge. The 
denial of the occurrence of gonorrhea in either parent is of no value. 




Fig. 17. — Diagram (anteroposterior) illustrating by the shaded portion (A) the situation of 
adenoid vegetations in the nasopharynx. 



Acute rhinitis occurring with an associated catarrh of other 
organs is an evidence of the general ill health of the child. It 
occurs with almost uniform regularity in the preemptive stage 
of rubeola, and at the onset of influenza, pertussis, and bronchitis. 

Inhalations of irritating vapors or of certain chemicals (chlorin, 
bromin, hydrochloric acid) may produce an acute rhinitis, and 
saturation of the system with iodin often results in the disease, 
the discharge having a peculiar fetid odor. 

Adenoid Vegetations. — It is very common to find that this 
is the cause of the occasional attacks of acute rhinitis, and the 



ACUTE NASAL DISCHARGE 



51 



condition is more apt to be evidenced in this form than in the 
form of a chronic rhinitis. Chronic rhinitis may be present, but 
it is not self-evident, the careful taking of a history being necessary 
to bring the fact out. 

Adenoids may be present so that they can be appreciated as 
early as the second month of life. This is unusual, however, for 
the time at which they are most in evidence is between the third 
and the fifth years. It is so frequently the case that enlarged 
tonsils are associated with adenoids that the presence of one 
should lead to a suspicion of the presence of the other. The 
symptoms are usually 
quite typical. Certainly 
after observing a num- 
ber of cases one is usu- 
ally able to diagnose the 
condition by the appear- 
ance of the child alone. 
I am not advocating this 
method of diagnosis, 
however, but simply 
stating what is a fact. 
A thorough examination 
should be made in every 
suspected case. 

The facial expression 
is quite characteristic ; 
it is somewhat dull, and 
the open mouth, the 

thickened lips, the absence of the groove over the alae nasi, the 
pinched appearance of the nose, and the prominent transverse 
vein at the root of the nose complete a picture which is simu- 
lated by no other condition. There is an inability to blow the 
nose when the growth is large, and as a result the nostrils are ob- 
structed by mucus. The voice assumes a nasal twang in many 
cases. 

When the history is taken, it reveals the fact that the child is 
very restless at night and takes cold very readily. If the adenoids 
have been long present, there is more or less abundant evidence 




Fig. 18.— A characteristic pose of child with adenoid 
vegetations. 



52 



EXAMINATION OF THE NOSE 



of stunted physical and mental development. Reflexes are as 
varied as is the susceptibility of children to certain impressions. 
Some of these reflexes are epistaxis, incontinence of urine, cough, 
muscular spasms, muscular twitchings, stammering, sudden 
and transient deafness, etc. Deafness of a permanent nature is 
sometimes an associated condition. 

The examination is so simple that it is a wonder that it is not 
more commonly practised. Upon an inspection of the mouth 
it is found that the hard palate is more arched than normal, and 
that the secondary teeth are irregular and inclined to project. 

When the tongue is 
depressed, the posterior 
pharyngeal wall is ob- 
served to be covered 
with a thick white 
mucus which flows down 
from the nasopharynx. 

An examination should 
then be made of the 

J nasopharynx. To ac- 

complish this, the exam- 
M iner takes a position 
behind and somewhat to 
the right of the child, 
who is seated upon a 
chair, or, better still, 
held firmly upon the 
mother's knee. The left 
hand of the examiner firmly restrains the head by pressing it 
against the left side of the examiner's body. When the child's 
mouth has been opened, the left cheek is forced by one finger of 
the left hand into the mouth and between the teeth, thus 
preventing closure of the mouth. The examining finger is then 
carried rapidly into the mouth and turned upward to the naso- 
pharynx, being carried back of the soft palate into the naso- 
pharyngeal cavity. 

If adenoids are present, instead of the thin mucous membrane 
normally covering the bony structures, one encounters a soft 




Fig. 19.— Adenoid vegetations, front " view of same 
child as in figure 18. 



ACUTE NASAL DISCHARGE 53 

mass, the feel of which is not unlike that of a mass of worms. 
When the finger is withdrawn, it is generally found to be covered 
with blood and tenacious mucus. I must emphasize the fact, 
however, that the presence of blood on the finger has no distinc- 
tive diagnostic value; its absence does not exclude adenoids. 

Adenoids might be mistaken for a polypus, but the chance of 
such an error is so slight when an examination of the nasopharyn- 
geal cavity is made by the finger that it need not be considered. 

Membranous Rhinitis. — This is an acute inflammation of the 
nasal mucous membrane accompanied by the formation of a 
membrane. The membrane is grayish-white, and if removed 
early in the disease, it leaves a raw and bleeding surface. More 
or less marked obstruction of the nose is usually the first symptom, 
but this results in mouth-breathing with its long train of conse- 
quent symptoms. One peculiarity of the nasal discharge is 
that it is scarcely irritating, and this serves to distinguish it early 
from acute rhinitis. The examination shows that one or both 
nostrils are filled with a tenacious mucus, and its presence should 
lead to a thorough cleansing of the nose and a search for mem- 
brane. 

Frequently there is some difficulty in examining the nares of a 
child, and if the tenacious mucus filling the nostrils (which has 
been described) is present, the administration of a few drops of 
chloroform or ethyl bromid is justifiable. After dilating with 
a nasal speculum, the nostrils are cleansed, and then the extent 
and situation of the membrane can easily be determined. Care 
must be exercised to determine the presence of a foreign bodv, 
for often this is the cause of the formation of a membrane. AYith 
a pair of small forceps the tenacity of the membrane is tested, 
but the whole procedure must be gently done. Late in the 
disease the membrane is removed without anv bleeding and with 
little effort; early in the disease more force is required and there 
is some bleeding. 

First of all, we must exclude the effect of the use of a caustic in 
the nose, the introduction of a foreign bodv, and an injury; and 
when that is done, then the diagnosis will rest between this form 
of rhinitis and nasal diphtheria. In the latter the discharge is 
early tinged with blood, although the amount may be very small. 



54 EXAMINATION OF THE NOSE 

The glands of the neck are somewhat enlarged and tender and 
there is apt to be more or less fever. 

Associated with the nasal condition, there is usually evidence of 
the disease in the tonsils, the pillars of the fauces, or in the naso- 
pharynx. The discharge is irritating to the parts it touches. 
In membranous rhinitis the discharge is not irritating to the skin 
and is not blood-tinged unless some violence has been used. The 
temperature is normal, as a rule. Despite the fact that the diag- 
nosis is usually easily made from the symptoms alone, a culture 
should be made in every case and the presence or absence of the 
Klebs-Loeffler bacillus determined. 



CHRONIC RHINITIS 

It may be a very difficult matter to distinguish between a 
mild chronic rhinitis and a continued series of acute attacks. 
This is complicated further by the fact that in the same child the 
character of the discharge may not be a constant feature. In a 
general way the chronic attacks differ from the acute in the 
absence of fever, by the prolonged course, and that while the 
discharge is usually more abundant, the swelling and the redness 
are much less pronounced. 

Undoubtedly most of the cases are produced in older children 
by improper breathing and from retained secretion due to the 
presence of adenoids. 

Hereditary Syphilis. — By far the most important bearing 
which chronic rhinitis has upon diagnosis is its occurrence in the 
infant. The only evidence of hereditary syphilis which we may 
have for a long time in the newly born is "snufhes." This may 
occur at times without nasal discharge, but usually there is a 
discharge of mucus, which is occasionally tinged with blood. In 
rarer instances there is epistaxis. Occasionally a child is born 
with the secondary manifestations of syphilis, but the rule is for 
them to appear later (that is, from the second to the sixth week, 
or at the third month). 

The infant experiences much difficulty in nursing, as the occlu- 
sion of the nose is usually complete. When the discharge occurs, 
it is generally continuous. The characteristic thing about syphilitic 



CHRONIC RHINITIS 55 

rhinitis is its persistent chronicity. Such infants become rapidly 
emaciated, and with the wrinkling of the skin, they have a pecu- 
liarly old look. The suspicion once aroused, examination should 
be made of the whole body, and evidences of the disease will 
almost invariably be discovered. 

Atrophic Rhinitis. — This is a chronic inflammation of the 
mucous membrane of the nose which results in an atrophy of the 
membrane and the turbinal bones. It is rare in children. 

The local symptoms are nasal occlusion by the presence of 
crusts, which the child removes several times daily. The odor 
from these crusts is fetid and is imparted to the breath. When 
the atrophic changes take place, which they do insidiously, atten- 
tion may be first attracted to the condition by the ozena. As 
the disease reaches the atrophic stage, dryness of the nose, of the 
pharynx, and of the larynx becomes the prominent feature. This 
is very noticeable in the mornings, producing the well-known 
hawking. 

Both posterior and anterior rhinoscopy reveal the presence of 
thick greenish or black crusts, adherent to the turbinate and 
septum mucous membranes and over the pharyngeal wall. The 
mucous membranes are dry, glistening, and swollen, and there 
may be ulcerated areas where the crusts have been dislodged. 

Foreign Body in the Nose. — This is met with as soon as the 
infant is able to get about the floor, and it is remarkable sometimes 
to observe the persistency with which some children will continue 
to place articles in the nostrils. Sometimes the habit is acquired 
of placing articles in the mouth, and these are swallowed and later 
vomited, and may lodge in the posterior nares. They act as 
sources of irritation and may result in ulceration. When the 
latter takes place, the discharge may become more or less fetid 
and irritating. 

Usually it is impossible to tell from the symptoms that a 
foreign body is present, for they so closely resemble those of acute 
rhinitis or even nasal diphtheria. The most characteristic 
symptoms are pain in the ear corresponding with the side on which 
the foreign body is located, unilateral discharge, and snoring 
which is suddenly developed in a child who previously rested 
easily. 



56 ■ EXAMINATION OF THE NOSE 

A positive diagnosis cannot be made without an examination 
of the nose, and if necessary, this should be done under primary 
anesthesia. Recently introduced articles will usually be found 
upon the floor of the nose, between the septum and the inferior 
turbinate. Later, the article may be forced further back. The 
examination entails that the nose be thoroughly cleansed before 
the search is instituted. 

Nasal Polypi. — These are rare during childhood. When 
present, the symptoms are of nasal obstruction associated with 
various reflexes. The amount of obstruction depends upon the 
size and number of the growths, sometimes one and at other times 
both nostrils being partly or completely occluded. Frontal 
headache is common. There is a quite constant discharge of a 
secretion which looks like the white of an egg, and if the growths 
are large or numerous, the voice assumes a nasal twang, which is 
quite characteristic. During damp weather the obstruction is 
increased, and with the advent of dry weather all the symptoms 
improve. 

The growths are sometimes large enough to be seen without a 
speculum. When the speculum is used, large polypi may be ob- 
served through the dilated nostril, and they usually lie between 
the septum and the outer wall of the nose. When small, they lie 
between the middle turbinate and the outer wall, or are attached 
to it. They resemble an oyster in color, and with the probe 
they are found to be freely movable and apparently without 
sensation. The probe may be passed freely about the growth, 
except at the point of its attachment. 

All other tumors in the nose are firmer and harder than polypi. 
The distinctive features of a polypus are its full, smooth surface, 
its mobility, lack of sensitiveness, its slow growth, and the free- 
dom with which it may be interfered with without occasioning 
bleeding. 

EPISTAXIS 
Usually the occurrence of epistaxis is readily recognized, 
because, as a rule, the blood flows more or less freely from the 
anterior nares. But it is not uncommon to find when the hem- 
orrhage has been small that the blood does not flow from the 



EPISTAXIS 57 

nostrils, but remains there until clotted, and is discharged in that 
form later; or there may be a clot noticed upon the posterior 
pharyngeal wall. In still other instances there will be no history 
of nose-bleed, but simply of the vomiting of blood. With such 
a history a thorough investigation must be made to determine 
the source of the hemorrhage, for it frequently occurs that a 
child will have a profuse hemorrhage from the nose while it is in 
the prone position, and the blood is swallowed and subsequently 
vomited. The alarm of the patient or its friends is then so great 
that no mention is made of any conditions within the nasopharynx 
which might account for the presence of the blood. 

In epistaxis the bleeding is generally capillary. If there is no 
history of traumatism, it is best to first examine the septum, for 
this is the most frequent site of hemorrhage; then the vault of 
the pharynx should be investigated. On wiping away the blood 
there will usually be found a bleeding point from which there is 
more or less oozing. If the hemorrhage is a recent one, a clot 
will be present; if more remote, there may be a dry, brownish 
or black crust, the removal of which generally results in fresh 
oozing. If the site of the hemorrhage is not found to be either of 
the parts which have been mentioned, then it will be a difficult 
matter to find the source. 

The causes of epistaxis are quite numerous, and may be divided 
into those which are general and those which are local. 

General Causes. — All conditions which favor congestion may 
influence the occurrence of epistaxis. Then there are various 
blood conditions which favor it, as hemophilia, purpura, scurvy, 
anemia, chlorosis, leukemia, syphilis, and rheumatism. 

In an otherwise healthy child, if epistaxis repeatedly occurs and 
the cause is undiscoverable, the strong probability is that it is de- 
pendent upon rheumatism. Very commonly a carefully taken his- 
tory will reveal the fact that the child has been the subject of indefi- 
nite pain which has not been severe enough to attract attention. 
An examination of the urine will at once reveal its turbidity and the 
presence of abundant uric acid salts. The further examination 
may reveal some chronic cardiac disease which has escaped at ten 
tion up to this time. 

Epistaxis may occur as an accompaniment of many acute 



^ 8 EXAMINATION OF THE NOSE 

diseases, and especially those of an infectious nature, but in this 
connection it has no special significance. During the course of 
nasal diphtheria it is usually of late occurrence, but, late as it 
may be, it is frequently the first symptom to attract attention 
to the situation of the membrane in the nose. 

It is not uncommon for epistaxis to occur in cardiac disease, 
and especially under those conditions in which there is increased 
arterial tension or a hindered return flow of the blood. If the 
bleeding occurs immediately after a severe coughing spell, it is 
strongly indicative of pertussis. 

When the cause of an epistaxis has been systematically searched 
for, and still remains obscure, it should arouse suspicion of a 
weakened heart action from some cause, probably organic. Peri- 
odical epistaxis is not uncommon, and in nearly every instance 
may be traced to malaria. 

There seems to be a strong predisposition in some children to 
the occurrence of nose-bleed; the slightest causes are sufficient 
to start in them a profuse epistaxis, despite the fact that they 
remain in perfect health, and that there is no evidence of any 
hemorrhagic tendency which is hereditary. 

Local Causes. — Under local causes traumatism is by far the 
most common, such as falls and blows upon the nose. In some 
children on the cartilaginous part of the septum there is a small 
group of thin- walled veins, and a blow or picking at this part of 
the nose may readily excite hemorrhage. Under certain condi- 
tions, as congestion or rheumatism, even the blowing of the nose 
may cause epistaxis, the blood coming from this point. 

Aside from what is strictly trauma, the presence of a foreign 
body in the nose may excite profuse hemorrhage. Some children 
have a strong disposition to push small articles into their nostrils. 
During acute rhinitis a small amount of nose-bleed may occur, 
b>ut it is not frequent. 

Other factors in the causation are ulcerations, varicosities, and 
severe catarrhal inflammations. Xew-growths may be accom- 
panied by epistaxis. Violent exercise and excessive study have 
been assigned as causes of nose-bleed, but they are active only 
in children who are generally debilitated. 



EXAMINATION OF THE LIPS, TONGUE, AND MOUTH 

MALFORMATIONS 

Harelip is one of the most frequent of the congenital defor- 
mities, and may be single or double. The fissure is generally 
situated just under the center of the nostril, and not in the median 
line. It extends in nearly every instance up to the nostril. In 
some of the cases there is simply an indentation in the lip. 

Cleft Palate. — It is somewhat unusual for harelip to occur 
without being associated with cleft palate. This is due to an 
imperfect closure of the fetal gap in this region. In contrast to 
harelip, cleft palate is in the median line and involves the soft 
palate and the uvula in many cases. If the cleft in the hard 
palate includes the alveolar border, it may leave the median line. 

Both harelip and cleft palate interfere seriously with nutrition. 

Hypertrophy of the tongue should be looked upon as a lym- 
phangioma. The tongue may be considerably swollen, so that it 
fills the mouth and may even protrude from it. Naturally, it 
interferes with perfect nursing, swallowing, and respiration. 

Tongue-tie is simply due to a congenital shortness of the 
frenum of the tongue and exists in all degrees. It may interfere 
with the protrusion of the tongue, or with its free use so as to 
interfere with nursing. 

Bifid uvula may be associated with cleft palate or mav exist 
alone, and is not an infrequent condition, although marked degrees 
of bifurcation are somewhat rare. 

Bifid tongue is exceedingly rare. 

THE LIPS 

Thick or thin lips are a racial characteristic, and in this connec- 
tion are of no value in diagnosis. But, on the other hand, a thick- 
ened lip may be part of the facies of cretinism, and the scrof- 
ulous diathesis may be indicated, in part, by a much thickened 
upper lip without any evidences of inflammation. 

59 



6o EXAMINATION OF LIPS, TONGUE, AND MOUTH 

Color of the Lips. — They are pale in anemia and cyanotic 
when the heart is acutely weak or there is much obstruction to 
respiration. They may become pale as the first indication of 
syncope. If upon exertion the lips of a child become bluish in 
color, it is strongly indicative of some cardiac disease. 

Unilateral deviation is in most cases attributable to the loss 
of some of the teeth or to their marked loosening; or cicatrices 
may be responsible for the deformity. With these two excluded, 
it is indicative of facial paralysis. 

Open lips, especially if there is an associated blueness, are 
suggestive of interference with nasal breathing, or of the presence 
of dyspnea. Open lips are part of the picture seen in prostration 
and collapse. 

If, in addition to being parted, the lips are loose and pendulous, 
it is indicative of paralysis, especially the post-diphtheritic form. 
In idiocy the lips are open and the lower lip is pendulous and 
loose, but this is a chronic condition and associated with other 
signs. 

In acute cases the lips may be open, with saliva dripping from 
the corners of the mouth, and this would lead one to suspect some 
condition within the mouth, as stomatitis. Mouth-breathers 
habitually keep the lips parted. 

Swollen lips are usually due to the bites of insects, but may also 
be due to local lesions of the mucosa from long-continued irritation. 
Cancrum oris especially is apt to cause a swelling of the lips. 
Primary swelling is not a usual occurrence, but secondary swelling 
is not uncommon (following or associated with perleche, cancrum 
oris, injury during convulsions, etc.). 

Twitching may be due to chorea, or if occurring while the infant 
is asleep, may be the first indication of the threatened onset of 
general convulsions. Under any circumstances it indicates an 
irritation of the nervous system. A convulsive contraction of 
the upper lip is quite indicative of abdominal pain. 

Eruptions About the Lips 
Herpes. — The lips are very frequently the site of the develop- 
ment of several small vesicles which occur in groups or clusters, 
finally rupturing and forming small crusts or scabs. These are 



THE TONGUE 6 1 

called herpes, and are known to the laity as "fever blisters" or 
"cold sores." The condition is very apt to occur during any 
catarrhal inflammation of the respiratory tract and malaria. Its 
common occurrence during pneumonia and epidemic meningitis 
gives to it a position of some diagnostic value. It never occurs 
during typhoid fever or tuberculous meningitis, so that this fact 
may be of much value in differentiation. 

Perleche is an infectious disease of the lips, which is first evi- 
denced by the lips becoming hot and swollen. This is accompanied 
by some itching and smarting, which causes the child to constantly 
lick the site of the trouble (the corners of the lips). Fissures 
quickly form in the mucous membrane, and these become worse 
with the constant irritation of the licking. The mucous mem- 
brane soon becomes macerated, thickened, and opaque, and comes 
off in patches and stripes. The disease lasts for about three weeks. 

The chief interest is in its differentiation from herpes and eczema, 
either of which may be associated with it. The swelling in 
perleche is greater than in herpes, and there are smarting and 
itching. From eczema the diagnosis is difficult at first, but the 
effect of treatment soon clears away any doubt. The constant 
desire to lick is a strong point in favor of perleche. 

Eczema may affect the corners of the mouth or the border of 
the lips, resulting in fissures or cracks which are quite painful and 
bleed easily. Usually there are other associated lesions in remote 
parts. 

THE TONGUE 

The examination of the infant's tongue is best made at the same 
time that the throat is examined, for what little information we 
obtain from its inspection is valueless if only the tip is observed. 
The laity lay great stress upon the value of such an examination, 
but the diagnostic value of an inspection is very much overesti- 
mated. 

Coated Tongue. — It has been taught and re-taught that the 
•condition of the gastro-intestinal tract was clearly reflected in the 
condition of the tongue's mucosa, and this is not so. Strictly 
speaking, the covering of the tongue is not mucous membrane, 
for embryonically it had its origin in the outer layer of the blasto- 



62 EXAMINATION OF LIPS, TONGUE, AND MOUTH 

derm, and is therefore a modified epithelium. Clinically it acts 
more like the skin than like mucous membrane. 

A coated tongue is the usual accompaniment of all febrile con- 
ditions. It is a perfectly normal condition in many children who 
are absolutely healthy. 

A dark-brown coating over the tongue may be seen in some cases 
of chronic indigestion, and the tongue has the appearance of being 
covered with fine black hairs; the diagnostic value of such an 
appearance, however, is nil. It is only necessary to remember 
its occasional occurrence, so that one may distinguish it from the 
black-stained tongue which is seen after the ingestion of certain 
drugs or foods. A more rare condition, which might be mistaken 
for it, is the formation of dark-brown crusts on the tongue in some 
cases of typhoid fever. 

Any coating of the tongue becomes more pronounced under 
any or all of the following conditions : 

(a) Immobility of the tongue, which prevents the cleansing 
which usually goes on, from constant activity. 

(b) The presence of fever, which dries up the normal secretions 
of the mouth. 

(c) The ingestion of certain drugs which reduce the flow of 
saliva. 

(d) Inflammations of the mouth, or other conditions which 
result in lessened secretion of saliva or its immediate expulsion 
from the mouth. 

The manner in which a coating clears is of much greater 
diagnostic value than the presence of the coating itself. In 
typhoid fever the tongue clears from the margins and the tip, 
and soon the anterior half of the tongue is clear in a triangular 
shape, with the apex toward the base of the tongue. In a condi- 
tion that might be mistaken for typhoid the coating is always 
uniform, and when it clears it does so uniformly. 

The "strawberry tongue" of scarlet fever is not of itself of 
much diagnostic value ; it is not typical, and its occurrence is late 
(second or third day). Of just as great value is the manner of 
its clearing. The tongue is gradually coated up to the third or 
perhaps the fourth day ; then it begins to clear, first at the tip and 
the margins, and within thirty-six or forty-eight hours it is. 



THE TONGUE 63 

entirely clear and of a bright red color, with the papillae much 
enlarged. 

Dry, glazed tongue is seen in those cases of dysentery which 
run a protracted course, and is indicative of the generally weakened 
condition of the child. The same kind of a tongue may occasion- 
ally be observed in acute enteritis and during the course of intes- 
tinal obstruction, and in either case is of ill import. 

Color of the Tongue. — This may depend upon the ingestion of 
certain foods, especially berries, or upon the local action of drugs. 
The poisons which are most commonly ingested by children give 
the following characteristic colors to the tongue, but reliance 
must not be placed upon these alone ; they are merely corrobora- 
tive evidences : 

Corrosive sublimate: the tongue is white and shriveled, with the 
papillae at the base very much enlarged. 

Sulphuric acid: it is first white, then turns gray, and finally 
exhibits a black slough. 

Phenol: the mucous membrane is shriveled into folds with 
brown or white spots appearing wherever the acid has touched. 
Within a few hours there appears a bright red zone about these 
spots and the color of the spot changes to a black. 

Oxalic acid: the tongue looks scalded, but in addition there is 
a thick whitish coating. 

Inflammation of the tongue is rare in childhood, but still may 
be occasioned by a sharp tooth or a bite received during a con- 
vulsion or a fall. The color is intensely red, but associated with 
it is much swelling. 

(For redness of the tongue see the following section.) 

Eruptions of variola, rubeola, and erysipelas may be seen on 
the tongue. 

Diseases of the Tongue 

Hypertrophy of the Tongue. — Aside from the congenital 
hypertrophy which has already been referred to, macroglossia 
may exist because of an increase of any or of all of the constitu- 
ents of the tongue. 

There may be either muscular or fibrous hypertrophy, cystic 
degeneration, or overdistention of the lymph-spaces with resultant 
cavernous lymphangioma. Hypertrophy of the lymphoid bodies 



64 EXAMINATION OF LIPS, TONGUE, AND MOUTH 

may cause lymphadenoma. No matter what the cause, the 
tongue may become too large for the mouth, and in severe cases 
protrusion will take place. When the condition is mild or just 
starting, the swelling of the tongue may force it against the teeth, 
and so result in injury to its membranous covering, this increasing 
the swelling. Even with a somewhat moderate enlargement, 
saliva dribbles from the mouth, and the ulcerations from injury 
produce an odor which is quite offensive. 

The condition is disgusting alike to patient and attendant, and 
is fortunately rare. 

Ulcers (other than those associated with disease of the mouth). 
— An ulcer on the tongue, and especially upon its under surface, 
is frequently due to the irritation caused by the eruption of a 
new tooth, or to injury caused by a ragged tooth. 

When the lower median incisors are sharp or ragged, any severe 
attack of coughing may be the means of producing an ulceration 
of the tongue or of its frenum. Two conditions are necessary: 
severe coughing and sharp-edged incisors. 

In nurslings coagulated milk may gather in spots upon the 
tongue and simulate ulcers. Their removal with a piece of cotton 
clears up all doubt as to their nature. 

Epithelial desquamation of the tongue takes place in des- 
quamative glossitis. (Such a condition is sometimes called lingua 
geographica.) The upper surface of the tongue is the part 
affected. The tongue exhibits several pale-pink islets about the 
size of a pea, where the epithelium has been denuded. These are 
surrounded by white circular zones of elongated filiform papillae. 
The favorite situation for these islets is along the margin of the 
organ. The shape of the islets is not constant; they increase 
somewhat in size, and as the edges of the whitish zones coalesce, 
there is a disappearance of the white color at the point of union, 
so that finally the tongue has the appearance of being marked 
with twisted lines. Hence the term, "geographical tongue." 
After a few days the whole tongue clears and there is a rapid 
return to normal. 

After the trouble has apparently subsided for several days 
there may be a fresh invasion, with the same process repeated, 
and this mav continue almost indefmitelv, so that the condition 



DISEASES OF THE MOUTH 65 

may persist for months. During all this time there is little or no 
discomfort to the child. It may occur in children of any age, and 
irrespective of whether they are sick or well. 

This condition bears no relation to any other disease, has little 
clinical significance, and is probably due to some microorganisms, 
the nature of which are still unknown. 

Acute glossitis is a rare disease among children, yet it may 
arise under the influence of traumatism, bites of insects, etc., to 
which infection is added. 

After a short period of soreness of the organ there are added 
stiffness and considerable pain upon motion of the member, and 
pain may also be referred to the muscles of the neck and jaw. 
Following this, the tongue rapidly enlarges, so that within twelve 
hours it is twice or three times the natural size. When this stage 
is reached, the tongue protrudes from the mouth and is almost im- 
mobile. Saliva constantly dribbles from the mouth and the tongue 
is heavily coated; dysphagia is extreme and speech impossible. 
The glands beneath the jaw may be much swollen and the temper- 
ature is raised slightly (about ioi° F.). 

Gangrene is the rule if the little one survives the threatened 
suffocation; but if neither happens during the first three days, 
the chances of resolution taking place are excellent, and within 
one week the normal condition is regained. 

The diagnosis must be made from acute edematous swelling due 
to affections of the floor of the mouth, and from acute ranula, 
which sometimes causes considerable swelling of the tongue. In 
either case this is done by searching the floor of the mouth for the 
primary lesion. 

DISEASES OF THE MOUTH 

Practically all the diseases of the mouth are the result of 
trauma or of infection. The cavity is certainly an ideal breeding- 
place for all kinds of organisms, and it is only by the action of the 
secretions and the constant cleansing which normally goes on 
that disease is not more common. Probablv the secretions act 
more emphatically in preventing disease than we are aware oi, for 
clinically it is a fact that with diminished secretion, or in the 
presence of conditions which disturb the composition oi that 
secretion, diseases of the mouth are more prevalent. 
5 



66 examination of lips, tongue, and mouth 

Diseases Unaccompanied by Odor or Ulceration 

Gonorrheal Stomatitis. — This disease is only liable to occur 
when there has been an injury to the mouth which has removed 
the epithelium. Subsequent exposure may produce it, but this 
is unusual. Yellowish- white patches are formed on the tongue 
and the hard palate and the gonococcus is found in the exudate. 
There is but little inflammation and tenderness, so that, further 
than a mild remonstrance at first, the infant does not object to 
being placed at the breast. It is very rare that the condition 
exists alone in the mouth, but it is generally associated with other 
evidences of gonorrheal infection. 

Acute Catarrhal Stomatitis. — This is the commonest affection 
of the mouth during infancy. It is a part of, or precedes, nearly 
all other forms of stomatitis. It may evidence itself by a general 
hyperemia and hypersensitiveness of the membranes, or there 
may be considerable inflammation with pain, tenderness, and 
increased secretion. 

The usual course in infancy is at first a reddening of the mem- 
branes of the tongue and gums (sometimes of all of the mucous 
membrane of the mouth). Salivation is invariably present and 
the secretion may be so acid that the lip becomes inflamed. The 
tongue has a white, furry coating which becomes gradually darker, 
then disappears piecemeal. 

The infant refuses to nurse after several attempts have been 
made to do so. The general symptoms are restlessness, slight 
rise of temperature, and possibly diarrhea of a mild type. 

In older children, in whom the disease is much less frequent, 
there may be added to the usual symptoms of pain, salivation, 
fever, and coated tongue, a decided swelling of the tongue, with 
indentures along its side from pressure against the teeth. If 
any odor is present, it is very faint and never disagreeable. When 
present, it is worse in the morning and is readily removed by 
washing out the mouth. 

This type of stomatitis arises from various causes : retention of 
particles of food in the mouth may result in their decomposition, 
and the irritation caused thereby may be the starting-point for 
the invasion of microorganisms. If the child happens to be in a 
state of malnutrition or poor health, or there is any factor which 



DISEASES OF THE MOUTH 67 

diminishes the flow of saliva, the growth of bacteria is favored. 
When they once gain a foothold, the products of the inflammation 
tend strongly to produce or invite secondary infections. 

Certain drugs, used either locally or internally, may produce 
it (acids, mercury, strong alkalis, etc.). 

Stomatitis Mycosa (Thrush, Sprue, etc.). — This is a par- 
asitic form of stomatitis. The spores of this causative fungus 
may be found in the mouth of the healthy infant, and in fact they 
are everywhere prevalent. All that is needed for their develop- 
ment is the favorable soil, and this may be produced by simple 
neglect of the mouth. Finding suitable soil, they multiply until 
they appear upon the surface of the mucosa of the tongue, the 
posterior surface of the lips and of the cheeks and gums, in the 
form of small white flakes. In some instances there is an exten- 
sion of the disease into the throat and esophagus. 

The flakes are entirely white, and at first are firmly attached to 
the surface, so that forcible removal leaves an abraded and per- 
haps a slightly bleeding surface. Later in the disease they 
separate from the surface spontaneously. Immediately around 
each spot the mucosa looks drier than normal. When neglected, 
several of these spots may coalesce. The disease is of itself pain- 
less, but the accompanying catarrhal stomatitis may cause 
considerable distress. 

This is essentially a disease of the first weeks of life, and while 
it may develop in children who have passed the early suckling 
period, it is then associated with other disease which has exhausted 
the system. Occurring under these circumstances it is a late 
happening and a serious one. 

The diagnosis is made by the mode of development and the 
nature of the spots, whose chief and constant characteristic is 
their entirely white color and difficult removal early in the disease. 

The general symptoms are those of the inflammation, and 
added to these or modifying them are the symptoms of the 
associated disease. 

Diseases with Ulceration and no Offensive Odor 
Stomatitis Aphthosa (Canker; Sore-mouth") . — This is char- 
acterized by the formation upon the mucous membrane of the 



68 EXAMINATION OE UPS, TONGUE, AND MOUTH 

tongue, cheeks, and lips of small, shallow, rounded ulcers which 
usually appear in successive crops. Sometimes the first appear- 
ance is of a solitary vesicular lesion upon the tonsil. It does not 
take long for the eruption to develop, for usually within twenty- 
four hours it has spread well over the parts. At first the ulcers 
are about one-eighth of an inch in diameter and covered with a 
yellowish exudate. The ulcers rapidly coalesce, forming large 
patches which may resemble a diphtheritic exudate. As the ulcer 
ages it assumes a dirty grayish color, or may be of a dirty yellowish 
hue, but in either case surrounded by a reddened zone. 

Salivation is excessive and excoriation of the lips and chin is the 
rule. One of the characteristics of this type of ulceration is the 
entire absence of fetid breath. Another is its common occurrence 
at the time of the first teething. 

The general symptoms are much the same as in the catarrhal 
form, but much intensified. Pain is much more of a feature in 
this form than in the simple catarrhal form. The duration of 
the disease is between one and two weeks. 

In diagnosis a distinction has to be made between this disease 
and ulcerative or diphtheritic stomatitis, as well as from the lesions 
of variola and varicella as they appear in the mouth. The situa- 
tion of the ulcers and the entire absence of fetor will exclude 
ulcerative stomatitis. The early appearance of salivation and 
the early disappearance of the coalesced patches tend to prove 
the non-diphtheritic nature of the disease. The history of con- 
tagion and the generally severe character of the initial symptoms 
of variola would help to differentiate it, while from varicella the 
distinction would be very difficult, and one might have to wait 
until the true nature of the disease was exposed by the subse- 
quent skin eruption. 

Syphilitic Stomatitis. — This is most frequently observed during 
the relapses. There are patches formed which are whitish and 
slightly elevated, with a papillary structure, and this feature is 
usually so decided that one may see several thickly crowded 
papillae tops forming the patch. They are situated upon the 
mucous membrane of the mouth, especially at the angles, and 
upon the lips, tongue, soft palate, and tonsils. Fissures of the 
lips and of the angles of the mouth are more distinctive of hered- 



DISEASES OF THE MOUTH 69 

itary syphilis when they occur during the first weeks of life; 
later than that they may appear without syphilis being the cause, 
and then they are usually the result of fever. 

Aphthae of the palate usually appears as a double lesion of the 
mucous membrane, but on opposite sides of the mouth where the 
hard and soft palates join. The ulcers are generally symmetri- 
cally located and are superficial and circular. They are of a 
grayish-yellow hue. 

They are in evidence for about three weeks and then gradually 
disappear. In abortive children they may spread and the two 
lesions may coalesce and others be formed, and under these 
circumstances the duration of the affection is from six to eight 
weeks. 

The condition is peculiar to the first few weeks of life. 

Diseases with Ulceration and Offensive Odor 

In this class of cases it is first necessary to determine the source 
of the odor, for even in the presence of ulceration within the 
mouth the odor may depend upon some associated condition and 
be entirely distinct from the ulceration. 

When the tongue is considerably coated, there is apt to be more 
or less disagreeable odor, which is readily removed by mouth- 
washing. A decayed tooth or the presence of decaying food in 
the mouth will give rise to some odor, but washing removes the 
smell, for a time at least, and in any instance, while the odor 
may be unpleasant, it is not offensive. Rhinitis is one of the 
most frequent sources of odor, and this can be distinguished from 
other causes by the fact that it is most noticeable during expi- 
ration through the nose. 

Other causes of offensive odor may be catarrh of the stomach 
with eructations of foul-smelling gas, bronchiectasis with fetid 
contents, and gangrene of the lung. 

Stomatitis Ulcerosa. — This condition may develop at any 
time of life, but is very unusual before the eruption of the tooth 
and after the ninth year. It depends largely upon a depraved 
condition of the general nutritive processes, and in rare instances 
may be directly traceable to metallic poisons, especially mercury 
and lead. During scorbutus it is by no means uncommon. 



JO EXAMINATION OF LIPS, TONGUE, AND MOUTH 

The lesions may occur upon any part of the mucous membrane 
of the mouth, but usually the very first point of invasion is at the 
junction of the tooth and gum. The intense, offensive odor of 
the mouth is generally the first thing noticed, then the ulceration 
is discovered. This is shortly followed by swelling of the gums, 
and they become intensely congested and somewhat friable, 
bleeding readily from slight pressure. The margins of the gum 
rise toward the crown of the tooth both internally and externally. 
The disease may continue until the soft and congested gum falls 
away from the tooth and pus forms in the intervening spaces or 
burrows through the alveolar process. Then two things may 
occur: the teeth become loosened and fall out, or the jaw may 
become necrotic. 

The ulcerative process may spread to the buccal mucosa, so 
that there is soon formed an ulcerated strip of a dirty yellow color, 
which soon breaks down, leaving an open ulceration with a foul 
bottom and undermined and broken edges. Associated with 
this, the whole cheek may be greatly swollen and the submaxillary 
glands enlarged. The tongue may be swollen and indented from 
the teeth. The general symptoms are unusually mild, unless 
sepsis occurs. 

Stomatitis Gangrenosa (Noma). — This is the most severe 
type of stomatitis as it occurs in childhood, and is fortunately 
not common. The time at which it is most likely to occur is 
during the interval between the first and second dentition. It is 
usually preceded by a catarrhal stomatitis which occurs in a child 
whose general nutrition and vitality are not up to standard. 

The gangrenous odor of the mouth is usually the first thing 
noticed, and then the ulcer is discovered. In the commencement 
the ulcer is a small spot of inflammation which appears upon the 
cheek, usually after two days of indefinite illness (slight fever, 
tender submaxillary and cervical glands, salivation). This red 
spot of inflammation rapidly deepens in color, so that it may soon 
become blue, purple, or black, and it rapidly increases in area as 
the necrosis spreads over the face. The destruction of tissue 
is rapid and very wide-spread, and if the unusual occurrence of 
spontaneous resolution takes place, the child is terribly deformed 



DISEASES OF THE MOUTH 7 1 

by the cicatrix. The general symptoms are severe and the cases 
usually result in early death. 

The diagnosis is made from anthrax by the history and the 
character of the ulcer; in anthrax there is at first a small pustule, 
which is rapidly formed into a solid but odorless scab, surrounded 
by new pustules or vesicles, and then only does a tumor of the 
soft parts appear. 

Diseases with Formation of Membrane 
Stomatitis Membranosa. — A pseudomembrane may form in 
the mouth and upon the lips during the course of the acute infec- 
tious fevers or as the result of irritants. These membranes are 
generally due to bacterial growth, and may be the forward exten- 
sion of a croupous angina. 

In very rare instances the condition seems to be primary. 
There is at times a very considerable systemic disturbance. The 
membranes may assume a darker color from exposure to the air, 
and this is especially true if any hemorrhage has taken place from 
fissures in the mucosa. Under treatment or with the exercise 
of ordinary cleanliness the membranes gradually disappear, 
leaving the mucous membrane somewhat reddened and denuded 
of epithelium. 

The diagnosis from diphtheria depends entirely upon the 
absence of the Klebs-Loefrler bacilli. From stomatitis mycbsa 
the diagnosis is made by the absence of the characteristic thrush 
fungus. 



THE FAUCES AND PHARYNX 

Between the mouth and the respiratory organs there is a 
passage which is lined with mucous membrane, and this is subject 
to the diseases which are common to all mucous membranes. 
Its situation makes it particularly liable to secondary diseases, 
while, upon the other hand, affections of the pharynx bear but 
little relation, diagnostically, to disease in other parts. 

For example, one could mention many instances like this: 
Tonsillitis occurs, and at once we are aware that it may be a mani- 
festation of a general condition of rheumatism. But when we 
endeavor to name the general affections which can be diagnosed 
by the appearance of the pharynx, we find that we are limited to 
just one — rubeola. 

The general symptoms of pharyngeal disease are certainly not 
marked, and it is absolutely essential that at every opportunity 
the pharynx should be examined. With the exception of diph- 
theria, erysipelas, retropharyngeal lymphadenitis, and tonsillitis, 
general symptoms are mild, but in these four they are often out 
of all proportion to the local condition. 

Pain is more or less constant in affections of the fauces and 
pharynx, because the functional acts require the use of all of the 
structures, and when there is ulceration or inflammation of a 
marked degree, movement causes pain. 

Odor of the breath and dysphagia are discussed in other sections 
(see pages 69 and 96). 

The Examination. — The examination of the fauces in children 
should be left as late in the general examination as possible, for 
after the throat has once been examined, the child is almost 
certain to rebel at any further interference, no matter how slight 
its character. The tongue and the uvula offer difficulties in 
examination. 

There is nothing quite so annoying as the attempt to examine 
the throat of a struggling child whose wilfullness is uncontrolled 

72 



EXAMINATION OF THE FAUCES AND THE PHARYNX 



73 



by the parent. The most satisfactory method is to have the attend- 
ant hold the child in the lap, facing the best obtainable light. 
Then she should be told to hold the child firmly against her side 
in a sitting position, while the arm that encircles the body confines 
the child's arms also, with a total disregard of the position of the 
child's head. 

Then, while so held firmly, the examiner with one hand presses 
the child's head against his side, at the same time and with the 
same hand forcing the cheek in between the teeth, so that 
the mouth cannot be 
closed until the exam- 
ination is complete. 
With the free hand 
the tongue depressor is 
used and the fauces in- 
spected. 

If the child is cooper- 
ating with the examiner, 
the instruction to en- 
deavor to say "ah" will 
cause the posterior 
pharyngeal wall to be 
brought more promin- 
ently into view. The 
same thing is accom- 
plished to an extent in 
a child who will not co- 
operate, by passing the 
tongue depressor back- 
ward until gagging is 
produced. 

The normal condition is as follows : The color is of a dark red, 
and the posterior pharyngeal wall shows little elevations (glands) 
upon its surface with visible but moderately sized vessels coursing 
through the mucous membrane. The tonsils are small and 
ordinary inspection reveals their whole surface. The inula 
hangs midway from the palate and has a rounded end. There 
is an oval depression in each tonsil with its longest diameter 
perpendicular. 




Fig. 20.— Illustrating a very good and common posi- 
tion for throat examination. 



74 THE FAUCES AND PHARYNX 

DISEASES OF THE FAUCES AND THE PHARYNX 

Acute Tonsillitis. — Acute inflammation of the tonsils may be 
limited to the mucous membrane, when it is known as simple 
catarrhal tonsillitis; or it may affect the follicles, constituting 
follicular tonsillitis. If the inflammation extends to the stroma 
of the gland, suppuration results, and we have suppurative 
tonsillitis. A peculiarity of all the acute forms is their liability 
to recur in the same individual. 

Simple Catarrhal Tonsillitis. — This is the most common 
form among children and is of importance because it leaves the 
child liable to the later development of other infections, which are 
favored by the lowered vitality and the abnormal condition of 
the gland. It is at. times epidemic, may accompany any of the 
aCute infectious diseases, and is precipitated by exposure to 
dampness or cold. 

The mucous membrane is swollen and congested. The gland 
does not show any marked enlargement, unless there is a chronic 
condition of enlargement present. If the case is moderately severe, 
the upper deep cervical glands may be enlarged and tender. The 
temperature is usually somewhat high, and the rise is sudden (to 
103 or 104 F. within twenty-four hours), but it just as suddenly 
falls. 

The usual course of an uncomplicated case is three to five days. 
It is not usual to see this disease existing by itself, but such is 
sometimes the case. Its most frequent occurrence is associated 
with acute pharyngitis, diphtheria, scarlet fever, and rubeola. 

Follicular Tonsillitis. — This is a common form of the disease 
and is an inflammation of the tonsillar crypts, and secondarily of 
the whole glandular structure. The general symptoms are usually 
the most severe ones and are the first ones noticed. The onset 
is sudden, with vomiting as the rule in infancy, but a chill or 
chilly sensations in an older child. The temperature then rises 
rapidly, and may range anywhere from 10 1° to 105 F., with the 
usual associated constitutional symptoms. 

The condition of the bowels is not constant, although in older 
children constipation seems to be the rule, while in infants there 
is generally a sharp attack of diarrhea with green stools. Natur- 



DISEASES OF THE FAUCES AND THE PHARYNX 75 

ally, with this condition in infants the attack is often attributed 
to gastro-enteritis. 

The first local signs are some swelling of the tonsils with a much 
reddened mucosa and the appearance of isolated yellow spots 
about pin-head size on one or both tonsils. These exudative 
spots mark the mouths of the crypts and project slightly from 
the surface of the tonsil. They can be removed with little effort 
and leave a slight depression, but if undisturbed, other follicles 
exude their contents, so that there is a punctate appearance with 
a tendency to coalescence. Upon swallowing there is usually 
some pain. The temperature persists for about four days, as a 
rule. 

At the onset the differential diagnosis is somewhat difficult, 
and in infants, if the general symptoms are relied upon alone, an 
error may readily be made by attributing the fever, vomiting, 
and diarrhea to gastro-enteritis. On the other hand, in older 
children the attack may at first simulate the onset of malaria, 
influenza, or pneumonia. If a routine examination of the throat 
is made in all cases of sick children, as it always should be, then 
the danger of mistake is infinitely less. 

From the general and also the local symptoms the diagnosis at 
first cannot be made from simple catarrhal tonsillitis, and it is not 
until the appearance of the plugs or spots in the crypts that one is 
sure about the type of the disease. When coalescence has taken 
place, then the condition is liable to be mistaken for diphtheria or 
for the membranous form of tonsillitis. The diagnosis of the 
latter depends largely upon the extreme fetor, the hard nodular 
adenitis, and the greasy friability of the membrane ; all associated 
with mild general symptoms. From diphtheria the distinction is 
made by culture, for diphtheria should be strongly suspected 
until disproved. 

In some cases the vomiting is so sudden and projectile, the fever 
so rapid in its development, and the throat so sore, that one 
might suspect scarlet fever, and under these circumstances the 
child should be isolated for twenty-four hours until the rash has 
had time to develop if the case is scarlet fever. 

Suppurative Tonsillitis. — This form may end in resolution, 
but usually goes on to the formation of an abscess. It is not so 



76 THK FAUCES AND PHARYNX 

frequent as the other forms, and almost invariably the cases are 
seen in children over eight years of age. It is the only form which 
is regularly unilateral. 

The onset resembles that of follicular tonsillitis somewhat, but 
the general symptoms are usually much milder, while the local 
ones are more marked. Then, after forty-eight hours, instead of a 
subsidence of the local symptoms (which is rather expected, 
because the general ones have shown much improvement), there 
is an apparent exacerbation. This is soon followed by a return 
of the general symptoms in all their former severity. 

Deglutition becomes quite painful and movements of the jaw 
cause much distress. The head is held stiffly and the mouth is 
usually partly open, with thick tenacious mucus and saliva flowing 
from the corners. The speech is thick, the tongue foul, and the 
breath very fetid. Sordes collect upon the teeth and pain may 
be complained of, radiating toward the ear. The effects of pain, 
lack of nourishment, loss of rest, etc., all show in the general con- 
dition, which is one of weakness. 

In the beginning inspection gives little data, and this should at 
once arouse a suspicion of suppurative tonsillitis, for in no other 
form is the pain so great at the onset with so little signs of disease 
in the tonsil itself. This is because the trouble is deep-seated 
at first. After twenty-four to forty-eight hours swelling is very 
noticeable, being rather behind the tonsil. Then the intense 
inflammation begins to show upon the mucous membrane of the 
tonsil, uvula, and fauces, with marked congestion and edema. 
However, less is gained in the way of diagnosis from inspection 
than from palpation, which should be practised whenever possible. 
By it, a fullness may be made out, or a point of fluctuation de- 
tected. 

Abscess generally forms in from five to seven days and opens 
spontaneously. The diagnosis should be made as early as possible, 
for with appropriate treatment the formation of an abscess may 
usually be avoided. 

Ulceromembranous Tonsillitis. — This disease may appear 
as a tonsillitis, a stomatitis, or a pharyngitis, and is due to a 
needle-shaped bacillus which is generally associated with a spi- 
rillum. The disease is communicable. 



DISEASES OF THE FAUCES AND THE PHARYNX 77 

There may be an involvement of one or both sides, and the 
chief characteristic is the formation of a greasy and friable mem- 
brane, which is followed within thirty-six hours, as a rule, by 
ulceration in the tonsil. These ulcers may be very extensive 
and have a punched-out appearance. From their presence the 
breath assumes a characteristically fetid odor. Salivation is 
sometimes extreme and deglutition is always painful. The 
lymph-nodes are hard and tender, but periglandular edema is 
not present. 

The general symptoms are very mild or wanting altogether. 

The differential diagnosis must consider diphtheria, follicular 
tonsillitis, and syphilitic sore throat. In diphtheria there is 
periglandular edema instead of the hard nodular adenitis, and the 
membrane adheres firmly instead of being friable, greasy, and 
easy to remove. 

The slight general symptoms or their entire absence, and the 
intense fetor to the breath, help to distinguish it from follicular 
tonsillitis. The absence of history of syphilis, the short duration 
of the disease, and the finding of the bacillus and spirillum of 
Vincent serve to clear up any doubt in regard to its specific nature. 

Chronic Tonsillitis. — This may be a congenital condition, 
but in most instances it is an acquired one, which may develop 
at any time of life. The close association of adenoids with hyper- 
trophied tonsils is a thing of common comment. 

In infancy the enlargement is principally an increase in the 
lymphoid tissue, the tonsil remaining quite soft. In older children 
there is connective-tissue increase also and the tonsils show 
sclerotic changes with deep fissuring and compression of the 
follicles. There are, of course, all degrees of enlargement, there- 
fore all degrees in the severity of associated symptoms. 

If the hypertrophy is quite marked, there is a peculiar quality 
to the tone of the voice ; articulation is indistinct. Snoring during 
sleep is usually a very noticeable feature. There are usually 
varied symptoms referable to the nervous system, and this is 
due to the fact that the rest is broken, that the retained secretions 
are swallowed, causing more or less digestive disturbance, and 
that the inability to breathe properly and freely interferes with 
the general nutrition of the child. The breath is usually foul. 



78 THE FAUCES AND PHARYNX 

Unless associated with adenoids, hypertrophy of the tonsils 
does not, as a rule, cause any severe symptoms. 

Adenoid Vegetations. — The immediate and remote effects of 
adenoid vegetations of the nasopharynx upon the development 
and the mortality of the child are far-reaching. Not only are 
the nutrition and growth of the child seriously affected, but he 
is constantly rendered more susceptible to infections of all kinds 
and his power to resist disease generally is markedly lessened. 

Adenoids consist of nodules of hyperplastic pharyngeal lymphoid 
tissue, gathered in masses and covered with ciliated epithelium. 
They are the result of an overgrowth of lymphoid tissue which is 
normally found in the vault of the pharynx. 

Of the early symptoms, the most constant are snoring at night, 
restlessness, tendency to epistaxis, susceptibility to atmospheric 
changes, and bad breath. Associated with one or more of these 
there may be the general symptoms of anemia, general malnutrition, 
mental deficiency, and various reflex nervous disorders. When- 
ever any of these are found, or when upon examination the tonsils 
are found to be chronically enlarged, an examination should be 
made for adenoids. 

W nen the case is fairly well advanced, the symptoms are those 
which are due to the chronic rhinopharyngeal catarrh and to the 
mechanical obstruction which is present. When the child is 
young, the former usually predominate, while in older children 
one finds that the obstructive symptoms are the most prominent. 

The chronic catarrh evidences itself by persistent nasal dis- 
charge, which is mucopurulent or seromucous, and may at times 
be tinged with blood, the latter generally following slight trauma. 
With every exposure to dampness or sudden change this discharge 
is aggravated, and this may be so noticeable that one obtains a 
history that at times the child is free from any discharge. 

The early obstructive symptoms are mouth-breathing, nasal 
voice, and lack of development. The mouth-breathing maybe con- 
stant or only noticed during sleep, when the child snores more or 
less loudly, for the difficulty of breathing is intensified when the 
child lies upon the back. The result is that the child's rest is 
always uneasy; it tosses about, trying to assume a comfortable 
position. The voice is rather muffled, and this is much more 



DISEASES OF THE FAUCES AND THE PHARYNX 79 

noticeable during the time that the child is suffering from an acute 
exacerbation of the catarrh. 

When the condition has persisted for a long time, the chest 
may become deformed to a considerable degree. The ribs are 
more prominent in front and the sternum is angulated forward 
at the manubrio-gladiolar junction. There may also be a deep 
depression over the lower part of the sternum. The ribs behind 
are frequently closely compressed, and the lower intercostal spaces 
obliterated. There may be, in addition to "chicken breast," 
"pigeon breast" or the "funnel breast." 

The question may arise, at times, as to whether the chest defor- 
mity is due to rachitis or not. This is frequently a difficult 
problem to settle satisfactorily, for the two conditions are so 
often associated. 

There is usually an inability to blow the nose, and this may be 
total or simply partial ; it may exist as an early symptom or may 
be a late one. 

The persistent interference with rest and proper sleep and the 
obstruction to perfect respiration soon result in a decided condi- 
tion of anemia and malnutrition, with all their associated and 
consequent symptoms. Various reflexes may also be excited, 
and it is not an unusual thing to find chorea, catarrhal spasm of 
the larynx, and incontinence of urine dependent upon the presence 
of adenoid vegetations. 

The natural course of the growths is to increase up to a certain 
point and then remain in a stationary state until the period of 
puberty, at which time atrophy usually sets in. Atrophy, 
however, is usually not complete, as I have taken the trouble to 
demonstrate many times. 

The mental condition of the child is generally markedly affected 
by the presence of the vegetations in the nasopharynx. There are 
noticeable forgetfulness and inability to set the mind for any 
length of time upon one subject. These children tire easily; not 
alone mentally, but physically also. 

Taken all together, these cases are better in summer, and with 
the return of winter there is a sure return of the troublesome 
conditions. There is practically no tendency to spontaneous 
recovery. 



So THE FAUCES AND PHARYNX 

In well-marked cases the diagnosis offers no difficulty. I do not 
think that it is necessary or wise to dwell upon the presence of 
protracted symptoms which might lead one to suspect the presence 
of adenoids. The examination to absolutely determine their 
presence is so simple and so quickly performed that whenever 
there is a suspicion that the child is so affected the examination 
should be made. 

The chief source of error will be in overlooking the existence of 
the growths — attributing the restlessness at night, the catarrh, 
the anemia, and the general symptoms to some other cause. It 
must always be remembered that the associated symptoms do not 
always act as a fair indicator of the size of the growths, a small 
growth causing marked general symptoms if confined in a small 
cavity. 

The best method of examination is digital exploration of the 
pharynx, and this is easily performed. A position should be taken 
by the examiner, behind and slightly to the right of the child, 
who should be seated in a chair or held upon the knee of an attend- 
ant. The examiner's left hand then encircles the child's head and 
neck, holding it firmly ; the right side of the head is brought against 
the examiner's side. When the mouth is forced slightly open, 
the cheek is pushed in between the teeth, preventing the closure 
of the mouth; this is done with the thumb or index-finger of the 
left hand. The forefinger of the right hand is now carried rap- 
idly back to the posterior wall of the pharynx, then turned upward 
to the nasopharynx, being pushed behind the soft palate into the 
cavity. 

Instead of thin mucous membrane covering bony structures, 
there will be found a soft mass filling the cavity more or less, if 
adenoids are present. When withdrawn, the finger will be covered 
with thick mucus, and possibly with blood. The presence or the 
absence of the latter is of no diagnostic importance. 

In the diagnosis a distinction must be made between adenoids 
and a fibroid tumor. The latter is much harder and firmer to the 
feel, but at the same time it is freely movable, and while it does 
not bleed readily, the absence of blood is not important, for with 
gentle examination it is commonly true that adenoids do not bleed. 

From a polypus which projects into the nasopharynx the diag- 



DISEASES OF THE FAUCES AND THE PHARYNX 



nosis is made by the finding of polypi in the nasal cavity also, and 
by the marked mobility of these growths. The rarity of polypi 
in early childhood and the frequency of adenoids is another deter- 
mining point. 

Malignant growths in this situation are extremely rare and are 
rapid in their development. 

Acute Pharyngitis. — Catarrhal inflammation of the pharyn- 
geal mucosa rarely occurs as an independent condition. Un- 




Fig. 21.— Examination of the nasopharynx for adenoid vegetations. (The examiner in this 
instance is left-handed.) 

doubtedly in some children there is a marked predisposition to 
attacks of the disease, but even in them there are usually associated 
lesions of the contiguous mucous membranes. 

In the beginning there is a sensation of more or less dryness 
and smarting in the throat, which is intensified by the inhalation 
of cold air or the atmosphere of a close room. Associated with 
this, is an almost continuous desire to clear the throat. 
6 



82 THE FAUCES AND PHARYNX 

The temperature rises to between ioi° and 103 F., and the 
onset of the pyrexia may be accompanied either by an attack of 
vomiting or by chilly sensations. In infants the constitutional 
symptoms may be very severe. But both in infants and in older 
children the general symptoms are of rather short duration, being 
more or less marked for twenty-four hours and then rapidly sub- 
siding in severity, so that within two or three days the child is 
apparently well again. There may be slight tenderness or swelling 
of the glands at the angles of the jaw. 

The throat upon inspection appears red and dry at first, but a 
few hours later that gives way to a glistening appearance which 
is due to the presence of a tenacious mucus. All the parts may 
be involved — pharyngeal wall, fauces, pillars, and uvula. The 
redness of the membrane may be punctate, with bright red 
papillae showing through the secretion which covers the duller red 
of the other parts. 

Rhinitis, tonsillitis, laryngitis, and stomatitis may one or all be 
associated with acute pharyngitis, and modify it to an extent. 

The diagnosis of pharyngitis is not so difficult, but to properly 
assign it to some underlying cause is usually quite difficult. It 
may be the expression of a disordered digestion or a rheumatic 
tendency, or depend upon other conditions, which it is quite nec- 
essary to recognize. 

When the symptoms are not well defined, the chief point in the 
diagnosis is to exclude scarlet fever and rubeola. In the former 
the redness is intense and diffuse, while in the latter there is a 
mottled redness and probably the presence of Koplik's spots. 
But in either instance it may be necessary to wait until such time 
as the cutaneous eruption might be looked for. 

Chronic Pharyngitis. — Repeated attacks of acute pharyn- 
gitis finally lead to a hypertrophy of the structures of the lymphoid 
ring. The posterior pharyngeal wall then exhibits a persistent 
hyperemia, with masses of apparently granular tissue, which are 
of about pin-head size. There may be a dry or a moist surface — 
usually the former. Hawking and coughing are frequent and the 
breath is apt to be offensive. The condition is not common during 
childhood, and in early childhood is very rare. 



DISEASES OF THE FAUCES AND THE PHARYNX 83 

Acute Uvulitis. — This may be primary or associated with any 
inflammatory condition in the pharynx. The uvula is usually 
swollen to about twice its normal size, and the mucous membrane 
covering is reddened and edematous. The result is that the base 
of the tongue and the posterior pharyngeal wall are irritated by 
the enlarged uvula lying against them and a troublesome cough 
results. This is usually worse upon lying down. As a rule, the 
cough is the only symptom which is noticeable, although there 
may be a slight elevation of the temperature for a few hours. 
Elongation of the uvula is usually the result of an acute uvulitis, 
but the condition is at times congenital. 

Retropharyngeal Lymphadenitis. — This is peculiar to the 
period of infancy and very early childhood, being rarely seen 
after the third year and occurring oftenest between the sixth and 
twelfth months of life. It consists of a collection of pus in the 
connective tissue beneath the mucous membrane of the pharynx. 
A predisposition is present in infants who are the subjects of 
rachitis, tuberculosis, or hereditary syphilis. 

Usually the onset is insidious and without any apparent cause, 
although at times a history may be obtained of otitis, nasal 
catarrh, or of some chronic inflammation of the tissues about the 
pharynx. The onset is peculiar in that the child is obviously 
very ill, but there is apparently nothing discoverable to account 
for it. This may be true until the pharyngeal swelling increases 
to such a size that deglutition becomes difficult and respiration 
is more or less interfered with. Quite early in the disease, when 
the abscess has reached a fair size, the child cries almost constantlv, 
and the cry rapidly assumes the character of a quack. Dyspnea 
may be marked. 

Finally, if the cause of the foregoing symptoms has not been 
discovered and relieved, there is a condition which supervenes 
which has many of the characteristics of croup, for bv this time 
the abscess has usually extended down so as to press upon the 
entrance of the larynx. Stiffness of the neck, nasal voice, mouth- 
breathing, and salivation may be present. With the inability 
to take any nourishment and the presence of the high temperature. 
the child rapidly emaciates. 

An examination readily reveals the cause of the symptoms; as 



84 THE FAUCES AND PHARYNX 

soon as the tongue is depressed, there is noticed a bulging forward 
of the posterior pharyngeal wall, and at times this is so marked 
that the uvula and the soft palate are pushed forward also, so that 
they appear to be in the middle of the mouth. By digital exami- 
nation fluctuation is detected in the bulging mass. 

The upper and the lower limits of the mass are easily felt, 
though it may at times pouch downward like a psoas abscess. 
When the collection of pus is very large, it may point in the neck, 
pushing the large vessels in front and giving rise to a pulsating 
tumor which simulates an aneurism. The usual duration is from 
two to three weeks. 

The chief error is in mistaking the condition for croup, but in all 
kinds of croup the stenotic breathing is more or less paroxysmal, 
while in this disease it is continuous, and the cough of retro- 
pharyngeal lymphadenitis has no croupy quality at any time. 
Then, again, the position in which the head is held is quite charac- 
teristic of abscess, and is observed in no other obstructive lesion 
(head inclined backward and toward the affected side). 



LARYNGEAL STENOSIS 

A stenosis of the larynx may possibly be caused by conditions 
outside of the larynx, which act by pressure, but such conditions 
are rare. In an overwhelming majority of instances the stenosis 
is due to diseases in the air-passages which result in swelling of the 
mucous membrane of the larynx. The way in which the majority 
of these conditions are produced is well understood, and the 
narrower the passage affected, the greater the result or effect 
following the stenosis. 

In the forms of stenosis which are characteristically sudden in 
their onset, as spasm of the glottis, false croup, and pertussis, the 
mode of production is not so well understood. There is no doubt 
that in all of them the essential factor is a spasm of the muscles 
which approximate the vocal cords, and in false croup there is the 
added factor of inflammation which persists after the acute sten- 
osis is over. 

It is a peculiar fact that young children are markedly suscep- 
tible to special neuroses affecting the larynx, and a characteristic 
feature of the inflammations of the larynx is the associated occur- 
rence of muscular spasm and consequent stenosis. This is one 
of the many expressions by the system of the peculiarly delicate 
reflex irritability of the child. 

The type of breathing which is consequent upon laryngeal 
stenosis is not difficult of recognition. The chief features are 
the inspiratory sound which is produced, the retraction of the 
yielding portions of the chest, and the use of the accessory muscles 
of respiration. The sound produced by inspiration is due to the 
forced passage of the air through the much restricted part. The 
access of air into the lung is much interfered with, and the inspira- 
tions become deeper, and there results the well-defined inspiratory 
retraction of the epigastrium, of the soft tissues above the clav 
icles and sternum, and of the lateral parts of the chest. 

The respirations are not alone more powerful, but they are 

S 5 



86 LARYNGEAL STENOSIS 

longer, and while under normal conditions expiration is a purely 
passive act, in laryngeal stenosis it becomes an active one. If 
the stenosis is not laryngeal, but the breathing is stenotic and due 
to causes outside of the trachea or the larynx (as causes in the 
lungs or bronchi), then the peculiar sound is absent, although all 
the other features may be present. 

In infants who cannot breathe freely through the mouth from 
any cause, the occurrence of a simple rhinitis will result in many 
of the svmptoms of stenotic breathing; but if forced to cry, the 
labored breathing is somewhat cleared up for a time. 



ACUTE STENOSIS 

The acute forms of laryngeal stenosis occur with most frequency 
during attacks of catarrhal spasm of the larynx and of membran- 
ous laryngitis. 

Catarrhal Spasm of the Larynx. — This is not common before 
the first six months of life, most of the cases being observed be- 
tween the ages of six months and three years. The disease seems 
to disregard the general condition of the child, for well-nourished 
and vigorous young children are attacked about as readily as 
poorly nourished and weakened ones. There is doubtless some 
hereditary influence which is active, some children being particu- 
larly prone to attacks upon the most slightly active causes. 

The attack is usually of quite sudden onset, although there 
may be some mild constitutional symptoms for some hours pre- 
ceding. These symptoms, if present, are generally a slight nasal 
discharge and more or less hoarseness. As a rule, early in the 
evening there is the occurrence of a teasing laryngeal cough, which 
is at times quite hard and is not frequent in the beginning. After 
a few hours of sleep, or about midnight, the attack comes on, and 
is evidenced at first by the child arousing suddenly with a hard, 
hollow, barking cough and some difficulty in respiration. If the 
dyspnea is very mild, the child may not waken. If the attack is 
one of moderate degree, the symptoms are somewhat severe for 
about fifteen to thirty minutes, and after that the signs of the 
stenosis markedly abate. 

In severe cases the attack may persist for one or two hours, and 



ACUTE STENOSIS 87 

there is marked dyspnea, particularly upon inspiration, and this 
is associated with a loud stridor as the air is forced through the 
much narrowed opening. The distress of the child is great; the 
pulse is rapid and the temperature normal or slightly elevated. 
Generally the child sits up and makes quite frantic struggles to 
regain its breath, or it may in rarer instances lie quiet and pros- 
trated, showing signs of lividity in the fingers and about the lips. 
The attacks are very apt to recur, and after several hours there 
is a gradual subsidence of all the symptoms and the child falls 
asleep. Upon awaking the next morning the little one is appar- 
ently well, except occasionally for the persistence of a slight 
hoarseness and infrequent harsh cough. 

On the second night, if the case has been untreated, there is, as a 
rule, a recurrence of the attack, which is, if anything, more severe 
than upon the preceding night. Upon the third night the attack 
is markedly reduced in its severity, and usually at that time does 
not amount to anything more than the occurrence of a harsh, 
croupy cough with some restlessness, disturbed sleep, and mild 
dyspnea. It is not unusual for a slight hoarseness to persist for 
several days following an attack, and this is irrespective of its 
severity. 

There is some danger of mistaking the disease for laryngismus 
stridulus, and some authors speak of both conditions as being 
similar. This is an error, for laryngismus stridulus is somewhat 
rare and is observed only in infancy and is the expression of an 
entirely different condition (malnutrition). In it we observe 
not only the peculiar form of breathing, but there is an absolute 
cessation of respiration, and this may be repeated several times 
daily over a protracted period. 

The greatest difficulty is encountered in clearly distinguishing 
catarrhal spasm from membranous laryngitis. The latter does 
not usually exhibit a sudden development of stenosis, the child 
showing symptoms of a catarrhal larvngitis generallv for two or 
three days preceding the severe symptoms. There has usually 
been some slight change in the voice and the occurrence of a mild 
and easy, infrequent cough. The symptoms are not relieved 
upon the following day, but grow gradually worse, so that in 
nearly every instance we observed slight symptoms for a day or 



88 LARYNGEAL STENOSIS 

two, growing gradually but progressively worse and with an added 
stenosis. The dyspnea is not so spasmodic in character, but is 
more continuous. If it is possible to obtain a well-defined history 
of previous attacks, it favors a diagnosis of catarrhal spasm, and 
if the inhalation of a small quantity of chloroform fails to have any 
appreciable effect upon the dyspnea, then the presence of a 
membrane is to be suspected. 

Membranous Laryngitis. — This inflammation of the larynx 
is characterized by the formation of a false membrane which 
depends for its existence upon bacterial infection. It may occur 
as a primary affection, but such is not usually the case, as it is 
much more frequently secondary to diphtheria of other parts. 
The membrane does not exhibit any peculiarities which are at all 
characteristic of the particular microbe which causes it. 

The membrane exists in all degrees of thickness and extent, so 
that in some cases it simply appears as a thin film, and in others 
is thick and practically occludes the opening in the larynx. Spasm 
is associated, and in many instances is the chief element of danger. 

At first it is impossible to distinguish the membranous from 
the catarrhal form, for there is the same hoarse cough and voice, 
which are accompanied with gradually increasing stridor, but 
these are not apt to be so abrupt in their onset or so severe in 
their course during the first few hours in the membranous form. 

The diagnosis is usually made by the progress of the disease, 
and if there is a gradual increase in intensity of all or most of the 
symptoms, the case is more than likely of the membranous form. 
On the other hand, one occasionally encounters cases in which 
for a week there are persistent hoarseness, teasing cough, slight 
constitutional symptoms, and moderate dyspnea. Then suddenly 
severe symptoms develop, the breathing becomes markedly sten- 
otic, prostration is rapid and extreme, and the child dies in a few 
hours. 

The usual course, however, is for the child to progressively 
become worse as time goes on, so that a child affected first in the 
morning will generally exhibit worse symptoms by night. Dysp- 
nea and hoarseness, which are slight at first, soon become marked, 
and the voice may be entirely lost. Upon the second day 
the symptoms are such that the chances of a mistake are mate- 



ACUTE STENOSIS 89 

rially lessened. The face wears an anxious expression and is apt 
to be quite pale, and the alae nasi dilate with the labored respi- 
rations. Stridulous breathing is very evident, and the dyspnea is 
much increased, causing real distress to the child. The unusual 
paleness of the face is often in marked contrast to the lividity 
of the extremities, although late in the disease the face may 
become much cyanosed. 

The rise in the temperature generally follows fairly closely the 
severity of the symptoms, so that when the symptoms are well 
developed and severe, the temperature may reach 105 F. or 
higher. When the disease has persisted for some days, the intellect 
is usually dulled or the child may pass into a comatose state. In 
children over three years of age the usual duration of the disease 
is from three to seven days, but in those under three the course is 
apt to be much more rapid and severe. 

The diagnosis must take into consideration several diseases which 
at first show a marked similarity. First, in regard to catarrhal 
spasm. A sudden development of a transient stenosis, in contra- 
distinction to a slowly but progressively developed one, is indica- 
tive of catarrhal spasm. The cough in spasm is at once hard, 
harsh, and teasing, and not gradually developed and moist. The 
cyanosis and dyspnea are somewhat transient in catarrhal spasm. 

From acute catarrhal laryngitis the diagnosis may be exceed- 
ingly difficult in the beginning. The use of the laryngoscope, 
which would furnish conclusive evidence in children approaching 
adult life, is valueless in young children, as they will not allow its 
use. Early in the disease the temperature is higher in the acute 
catarrhal form, the dyspnea is inclined to be paroxysmal, is 
chiefly inspiratory, and worse during the night. 

Dyspnea in the membranous form is constant, progressively 
increases, and is expiratory as well as inspiratory. In the catar- 
rhal form the voice is hoarse but not lost. The association of 
enlarged glands, membranous patches in the throat, and the 
presence of albumin in the urine (if it has been previously free 
from it) would all indicate the membranous form. 

In any event an examination must be made of the secretions 
of the throat, and as it is well-nigh impossible to get a specimen 
from within the larvnx, the smear must be taken from sonic of 



90 LARYNGEAL STENOSIS 

the adjacent structures. In about 80 per cent, of the cases the 
membrane is due to the Klebs-Loeffler bacillus, and if this is found, 
the case is one of undoubted membranous laryngitis. The 
absence of the bacillus proves nothing. 

Retropharyngeal lymphadenitis may for a time simulate mem- 
branous laryngitis, but digital exploration will soon clear up any 
doubt that may exist. A foreign body exhibits some signs which 
are misleading, but the history is usually clear on this point and 
there is a very sudden onset of the symptoms without any rise 
of temperature. 

Acute Catarrhal Laryngitis. — This disease is not so common 
as catarrhal spasm, but is apt to be more severe. It occurs with 
most frequency between the ages of two and five years. Except 
as it is due to injury, it does not occur as a primary disease, always 
being secondary to some disease of the respiratory tract or to one 
of the infections (especially rubeola, variola, and scarlet fever). 

The symptoms in the beginning are a characteristically harsh, 
barking, violent cough, which is worse during the night and is 
associated with hoarseness. These may continue to be the only 
symptoms noted, or they may be accompanied with slight consti- 
tutional disturbances, as slight elevation of the temperature, 
general malaise, and anorexia, all of which persist for a few days 
while the child protests against being confined indoors. 

Even in these mild attacks in older children the tendency to 
relapse from slight causes is marked. On the other hand, the 
child may be seized rather suddenly with the disease and be 
aroused during the night with all the classic symptoms of an attack 
of croup, the evidences of air-hunger being particularly obvious. 
Generally such an attack quickly subsides after a vomiting spell, 
and the child falls asleep, showing little evidence of his recent 
distress and struggles. Or in other instances the attack may 
persist up to the point of extreme exhaustion, the violent efforts 
to obtain relief resulting in pulmonary congestion from aspiration 
of blood. When the resulting carbon dioxid narcosis has super- 
vened, then there is usually a relief from the dyspnea, for the 
spasmodic element is abolished. There is a tendency to recurrence 
upon the two following nights. 



ACUTE STENOSIS 9 1 

When the child is very young or in a poor physical condition, 
death may take place during the attack. 

The differential diagnosis from other forms of laryngitis has 
already been considered. 

Edema of the Glottis. — While this condition is rare in early 
life, still it is occasionally the cause of laryngeal stenosis in chil- 
dren. It is characterized by a long period of inspiratory dyspnea 
and stenosis which may lead to asphyxiation. There is an effusion 
into the submucous cellular tissue, the infiltration of serum being 
chiefly in the epiglottis and aryepiglottic folds, so that the swelling 
which takes place causes the appearance of rounded swellings 
projecting on both sides of the superior isthmus. These are 
readily detected by digital examination. The voice usually 
remains clear, as the vocal cords are not involved. There is 
generally a constant desire and effort to clear the throat, so that 
the associated cough is ineffectual and wearing. The development 
of stenosis is both rapid and severe. 

If the cause of the edema is an inflammatory one, then there are 
pain and tenderness. In addition to the symptoms mentioned, 
there are those of the original disease, to which this is second- 
ary. 

The exciting cause of this condition may be the presence of a 
foreign body, the swallowing of acids, strong alkalis, or hot 
liquids, the inhalation of steam or irritating vapors, or it may be 
due to anything which causes a local irritation. In other instances 
it follows the occurrence of the acute infectious diseases. It is 
most frequently observed as a verv serious complication of serious 
disease of the kidneys, the heart, the lungs, or the liver. 

A rare disease in itself, it is rarely evidenced as an angioneurosis. 

The diagnosis is made by direct inspection or, better still, by 
digital exploration. 

Submucous laryngitis is almost identical with edema of the 
glottis, but differs in being an inflammatory form of edema which 
is dependent upon some adjacent inflammation. The examina 
tion shows that all the structures around the upper opening of 
the larynx are intenselv reddened and inflamed and the epiglottis 
is observed to be swollen and thickened (seen by depressing the 
tongue thoroughly). 



92 LARYNGEAL STENOSIS 

Foreign Body. — In the diagnosis of a foreign body as a cause 
of acute laryngeal stenosis the history is of great value. Such 
bodies are most apt to be drawn into the child's larynx during 
coughing, laughing, or crying. It is also common for children to 
go to sleep with small articles in their mouths. Hasty or imper- 
fect mastication is another element. If the child has a paralysis 
of the laryngeal muscles, then such an accident is very much 
favored. The possibility of lumbricoid worms finding their way 
into the throat must not be forgotten. 

The symptoms in the beginning are modified by the size, shape, 
and location of the body. Cough (the effort to expel the foreign 
substance) is generally severe and prolonged, so that the child 
is soon exhausted. This is associated with more or less dyspnea. 
Both of these may suddenly subside (as the body slips into a less 
irritating and obstructive position), only to return again within 
a few hours. 

The diagnosis is generally clear from the history, but at times 
this may be wanting, and then the case is one of considerable 
difficulty. In any case of doubt digital exploration is the quickest 
method of determination, and it may be necessary to practise 
this with the child in the inverted position. The x-ray will suffice 
to locate the foreign body if it possesses enough density. 

Retropharyngeal lymphadenitis is by no means uncommon, 
but is often overlooked as a cause of laryngeal stenosis, and this 
is particularly true of infancy. It is due to an inflammation of 
the deep lymphatic glands which receive the lymphatics of the 
tonsils, soft palate, and pharynx. The onset is singularly insid- 
ious, and although the child seems very ill, there is apparently 
nothing to account for it. Finally, as the pharyngeal swelling 
appears, deglutition is very painful and the symptoms of stenosis 
appear. These come on about seven to fourteen days after the 
first signs of the indefinite illness. The only means of positive 
diagnosis is by digital exploration of the pharynx (see page 84). 

Laryngismus Stridulus. — This is not a common condition and 
is peculiar to infancy. It is a neurosis purely and must not be 
confused (as it is by some authors) with catarrhal spasm of the 
larynx or acute catarrhal laryngitis. The neurosis manifests 
itself in an irregular spasmodic action of some of the respiratory 



ACUTE STENOSIS 93 

muscles, and is most often observed as a spasmodic contraction of 
the adductors of the glottis, interfering with the free access of air. 

Its occurrence closely corresponds with that period of life in 
which the nutrition is apt to be faulty (up to the eighteenth 
month), and its association with rachitis is marked. In a large 
proportion of the cases there is craniotabes also, and the associ- 
ation with rachitis is so pronounced that some authors state that it 
is invariably of rachitic origin. Occurring as an indication of rachi- 
tis, it precedes the time when there is any marked bony change, 
so that its recognition is valuable for the institution of preventive 
measures. The marked instability of the nervous equilibrium of 
rachitic and malnourished children is undoubtedly the predispos- 
ing factor in its occurrence. 

The attacks may occur at any time of the day, during waking 
or during sleeping hours. The attacks are mild in the beginning, 
and this quality causes them to be overlooked for a long time, 
but they become progressively more severe as time goes on. 

The attack is always sudden. There is a spasmodic inspiratory 
stridor, accompanied with a crowing sound as the air is rushed 
through the much narrowed glottis. The head is thrown back- 
ward and the face becomes first pale and then possibly livid as 
respiration is arrested. In other instances the reverse is the 
order, the crowing sound not being evident until the spasm shows 
a period of relaxation. Then, again, there are several atypical 
attacks. It may occur simply as a spell of "breath-holding" 
during anger or fright. There may be a series of audible sobs, 
ending in a whoop which somewhat simulates pertussis. It may 
occur simply as though the infant was catching its breath. It 
may be only evident for a time when the infant awakens, and then 
is observed as a short inspiratory sob or crowing. 

If the attacks are at all severe, the infant is left slightly weakened 
and perhaps drowsy. When the attacks are severe, the respi- 
ratory muscles are held rigidly in a state of extreme inspiration 
and consciousness may be lost. Carpopedal spasms and general 
convulsions may follow. The inclination to relapses is very 
strong as long as the causative condition (malnutrition) is present. 
The attacks may occur several times each day or may be separated 
by more or less protracted periods. 



94 LARYNGEAL STENOSIS 

In the differential diagnosis the main points to be considered 
are the repetition of the attacks, the general evidences of a rachi- 
tis or chronic state of malnutrition, and the age of the infant. If 
tetany is present, then the diagnosis is simplified. 



CHRONIC STENOSIS 

When the larynx is affected by a disease which causes a chronic 
stenosis, the voice loses its normal tone and becomes much harsher 
than usual. In other cases the voice is entirely lost for a time. 
The most frequent cause of such a condition is chronic laryngitis, 
and less frequently syphilis and new-growths. 

Chronic Laryngitis. — This disease is usually consequent upon 
repeated acute attacks, and is often associated with tonsillar 
enlargement and its usual companion, adenoid vegetations. There 
is a peculiar hoarseness or huskiness to the voice which is chronic, 
but subject to the occurrence of acute exacerbations from very 
slight causes (as fatigue, exposure to cold or dampness, inhalations 
of anything irritating, etc.). Sometimes, but not always, there 
is an ineffectual cough present and a constant desire to clear the 
throat. The symptoms are always improved under the influence 
of dry and warm weather. 

Syphilitic Laryngitis. — If hoarseness occurs in early life and 
is persistent, it is always suggestive of syphilis, and while the 
invasion of the larynx is not so common as affection of other parts, 
still one must be on his guard to diagnose the case early. When 
there is a perfectly clear history, or when there are unmistakable 
signs of the disease, the diagnosis is easy enough. But a great 
difficulty at once arises if the invasion of the larynx is the only 
apparent manifestation of svphilis, as it occasionally is. The 
favorite site is the epiglottis, and the favorite lesion is condyloma. 
It appears as a thickened, deformed, hollow cylinder of a whitish- 
red color, and may sometimes be recognized without the use of 
the mirror, but in most instances the examination must be thor- 
ough to discover the lesion. 

When there is a suspicion aroused, the anus and the corners of 
the mouth should be examined for evidences of an old syphilitic 
scar. The remains of old condylomata may be discovered in any 



CONGENITAL STENOSIS 95 

situation. Usually the invasion of the larynx does not take 
place until between the ages of three and ten, because of the 
tendency to occur only in relapses of the disease. 

Tubercular Laryngitis. — This probably never occurs as a 
primary disease in children, but is always secondary to disease in 
the lungs. The disease really belongs to the period of late child- 
hood, and even at that period is rare, so that the disease may be 
considered almost as a curiosity. 

The few cases that have occurred have been evidenced by 
constant and more or less severe pain, harsh voice, and cough of 
a teasing character. The symptoms of the disease in other parts 
are well defined before the occurrence of the laryngitis. 

Tumors of the Larynx. — In childhood these are almost always 
papillomata, and the growths may be single, multiple, sessile, or 
pediculated. The first symptoms are generally a chronic hoarse- 
ness and a paroxysmal cough, which is soon associated with loss 
of the voice. The cases are in the beginning very similar to chronic 
laryngitis, and a positive diagnosis involves the use of the laryn- 
goscope and the detection of the growths which may be attached 
to any part of the larynx. 

CONGENITAL STENOSIS 

Congenital Laryngeal Stridor. — This is a rare condition, but 
one which must not be confounded with laryngismus stridulus, 
which occurs in later infancy. The act of respiration is accom- 
plished with a purring sound which may terminate in a distinct 
crowing sound. This is constant and is increased by excitement. 
It disappears during the first hours of sleep, when unconsciousness 
is profound. The voice (as evidenced by the cry) remains clear 
and there are no associated symptoms of any kind. A disappear- 
ance occurs later in infancy. 



DYSPHAGIA 

Dysphagia is a symptom which is common to all the affections 
of the esophagus. It varies from the simple dysphagia which is 
due to pain and that which is dependent upon complete obstruc- 
tion of the tube. This latter type is due to pressure outside of 
the tube, to disease of the tube, or to the presence of an obstruc- 
tive body in the tube. 

The esophagus is in close contact in some part of its structure 
with the trachea, the thyroid gland, the left bronchus, the bron- 
chial glands, and the arch of the aorta, so that any condition 
causing enlargement of these structures may bring about dyspha- 
gia. With the trachea affected, dyspnea is prominent; enlarge- 
ment of the thyroid gland is easily demonstrated by palpation 
and inspection. The other named structures, being enlarged, 
cause pressure, and therefore dysphagia, by pressing the tube 
against the vertebrae. This is particularly true of enlarged bron- 
chial glands. 

It is easy to see how organic disease of the tube would result 
in difficulty in swallowing. This might be occasioned by an acute 
inflammation or by a chronic one. In the acute forms the act of 
speaking is also painful and the pain is usually of a raw or smarting 
character. In the chronic forms swallowing of liquids is, as a rule, 
easy and painless; speech is not painful and there is an abundant 
secretion of viscid mucus. Stricture generally follows traumatic 
inflammation, after a long period (three to six months), is gradually 
developed, painless, and is readily located by the use of the 
bougie. 

Dysphagia which is excited by the presence of a foreign body 
is usually not difficult of recognition and depends upon two things : 
the presence of the body and the excitation of spasm. Dyspnea 
is associated with the dysphagia, and its degree depends largely 
upon the size of the obstructing mass. The spasm causes regur- 
gitation of the food. 

96 



DYSPHAGIA 97 

Of the functional affections, spasm is the most common. It 
occurs in children whose nervous systems are very irritable. The 
attack usually comes on while the food is being taken, and it is at 
once regurgitated, after which swallowing is accomplished slowly 
if it is done at all. In paralysis the difficulty of swallowing is the 
main symptom, and as the larynx is usually paralyzed also, there 
are the associated symptoms of the two. Paralysis is very rare. 

The phlegmonous anginas, retropharyngeal lymphadenitis, 
severe diphtheritic and scarlet fever throats all cause more or less 
dysphagia. The erosions which are sometimes left on the tonsils 
after the diphtheritic membrane has cleared off constitute a very 
common cause. 

Dysphagia may be complete in hydrophobia. In the inherited 
stenosis, if there are diverticula, the food gets into these and may 
be expelled some hours later. Congenital malformations, like 
cleft palate, and paralysis of the soft palate which follows diph- 
theria, both cause considerable dysphagia, but it is always accom- 
panied with choking. 



DISEASES OF THE ESOPHAGUS 

Malformations. — These are very infrequent, and only such will 
be mentioned as are of diagnostic import. 

A congenital narrowing of the esophagus near its lower end may 
allow some of the food to pass into the stomach, while a portion 
may be regurgitated. Under such conditions the tube becomes 
gradually enlarged above the constriction and the digestion may 
be fairly good. The stools are scanty, however, and the usual 
outcome is that the infant rapidly succumbs to an acute inanition. 
Tracheo-esophageal fistula generally terminates by the infant 
dying with an aspiration pneumonia. 

Leaving malformations out of consideration, the esophagus is 
liable to all affections which arise in mucous membranes, but its 
histological structure, its functions, and its position protect it to a 
marked degree, so that it is true of childhood, at least, that 
affections of the esophagus are very rare. 

Acute esophagitis may be of two types — catarrhal or corro- 
sive, the latter being the most frequent form. The catarrhal 
form is of no clinical importance and is rarely met with. It may 
be due to traumatism w T hich may excite a simple catarrhal inflam- 
mation or there may be deep ulceration from injury. The only 
symptoms are dysphagia and slight elevation of temperature. 

Corrosive esophagitis depends usually upon the same causes as 
does corrosive gastritis — the swallowing of corrosive poisons. Fre- 
quently the brunt of the action of the poison is borne by the 
esophagus, and the effects may be very superficial or, on the other 
hand, very deep. If the epithelial layer alone is involved, there 
are no appreciable consequences, but if the destruction extends 
deeper than that, the results are usually serious. 

The early symptoms are not clearly defined from those of 
inflammation of the mouth, the pharynx, and the stomach. There 
is a burning or smarting sensation in the parts, accompanied by 
intense thirst and spasms of the esophagus at every attempt to 

98 



DISEASES OF THE ESOPHAGUS 99 

swallow. Deglutition is very painful and usually impossible. 
Following this, there is a period of acute inflammation which 
persists for a few days, during which time the pain is much in- 
creased and the danger is from edema of the glottis. Then comes 
a period of freedom from all symptoms until the time that con- 
striction is apt to take place, and this is from three to six months 
afterward. 

Retro-esophageal abscess is rarely diagnosed during life, 
although it may have been suspected. The only marked symptom 
is dyspnea, which is most pronounced upon inspiration. The 
condition might be suspected in tuberculosis of the lower cervical 
or the upper dorsal vertebrae when sudden inspiratory dyspnea 
appears. a at r» 



APPETITE AND THIRST 
THE APPETITE 

Anorexia. — Loss of the appetite may be due to many diseases, 
and is a constant feature of all the organic diseases of the stomach. 
In the so-called functional disturbances of the stomach and 
intestines anorexia is usually marked, but it is by no means a 
constant symptom. It may depend upon conditions remote from 
the stomach, but which affect that organ reflexly. and in this 
connection cerebral irritation occupies first place. The emotions 
are very frequently the cause of loss of appetite. 

A moderate gastritis accompanies all fevers, and loss of appetite 
is a constant accompaniment of elevated temperature. This is 
more marked during the course of some fevers, but is never so 
prominent as it is in epidemic influenza — a point which may be of 
value sometimes in differential diagnosis. 

Loss of appetite is sometimes the chief complaint which the 
parents of children of school age make, and in nearly every in- 
stance the cause will be found in an anemic condition of the 
child. No matter what the type of anemia, anorexia is usually 
a marked feature. That the lack of desire for food is due to the 
anemic state may be demonstrated by the discovery of other symp- 
toms, for these children are usually narrow-chested, pale, muscu- 
larly weak, easily fatigued, restless at night, and inclined to mental 
morbidity. The tongue is usually clean. 

A somewhat similar picture might be given if the child was 
suffering from chronic gastric indigestion, but the tongue is then 
more or less thickly coated and nausea is present at times. To 
exclude nervous indigestion, an examination might have to be 
made by stomach washing. 

In hysteria the first indication of the condition may be a loss 
of appetite, and this may show itself as a total loss or as an aver- 
sion to certain articles of diet. Acting under the influence of an 
idea, to excite sympathy, to attract attention, or to become thin, 



the appetite ioi 

there may be a marked reduction in the amount of food taken or 
there may be total abstinence. The usual form, however, is that 
several articles of food are placed under a ban and are absolutely 
refused. 

When the anorexia amounts to a disgust for food and gastric 
and cerebral influences are excluded, the possibility of suppura- 
tion going on somewhere in the body should be thought of and 
determined. When the taking of food is accompanied by pain, 
the child very naturally refuses to partake of it, so that anorexia 
becomes a part of dysphagia at times and is always associated with 
those conditions in the mouth and fauces which are accompanied 
with inflammation. 

Increased Appetite. — This should be expected after any illness, 
whether it be acute or chronic, and which has interfered with the 
child's nutrition or which has taxed the strength of the little one. 
It is desirable and natural only up to that point when the child 
is restored not to its former condition necessarily, but to that 
condition which is normal for a child of corresponding age and 
size. 

If the appetite goes beyond this point, it is then an evidence of 
gluttony — a condition or habit which is not uncommon in child- 
hood, and especially so among nurslings. It is one of the most 
prolific causes of gastric disorder and lays the foundation for the 
common inflammatory diseases of the stomach and intestines to 
which children are so prone. Other than this, it is a peculiar fact 
that it is very commonly the first symptom of marasmus : the child 
wants to nurse constantly. Gluttony is very common among 
rachitic children, idiots, and those suffering with diabetes. In 
chronic diarrheas its existence is of somewhat different import; 
it is still gluttony, but dependent upon the child's craving for 
fluid, and the liberal administration of fluid internally and exter- 
nally soon relieves the situation. 

After an attack of vomiting there is very apt to be increased 
craving for food, unless pyrexia is present. During the course of 
pertussis, when there is much vomiting, there is usually an in- 
creased appetite, and this may show itself immediately after an 
attack of vomiting. The presence of intestinal parasites, particu- 
larly tapeworm, generally results in a capricious appetite: one 



102 APPETITE AND THIRST 

time there is a partial anorexia, and at the next meal the appetite 
may be gluttonous, the latter being the most frequent occurrence. 

Pica. — This is a habit neurosis which evidences itself in per- 
verted appetite. There is no end to the number or variety of 
things which may be ingested. This disorder is distinct from 
bulimia, which is simply an exaggeration of the normal appetite, 
for in pica the appetite is not necessarily increased, but is per- 
verted. 

As an etiological factor age has little, if any, influence, but a 
marked hereditary influence has been noted. How much of this 
is simply due to instability of the nervous system is hard to deter- 
mine. Malnutrition seems to be a strong factor, as is also anemia ; 
but when one comes to examine into these factors, it is hard to 
tell whether they may be predisposing causes or not. Feeble- 
minded children are particularly predisposed to pica. It is a 
frequent manifestation of hysteria. 

Imitation is probably the most prolific cause, and given a child 
with a strong neurotic inheritance, it requires but little suggestion 
to determine the formation of the habit. Among school-children 
it is common to find that several companions are addicted to the 
eating of chalk, paper, etc. 

In infancy the habit is readily formed by the conveyance of 
certain things which the infant picks up and carries to the mouth ; 
this is done repeatedly until a habit is formed. Once formed, 
there is a constant desire to place all sorts of articles in the mouth. 
Many of the cases have been associated with the presence of 
worms in the intestinal tract. 

The symptoms are easily summed up in the fact that there is 
perverted appetite, the ingestion of different articles causing va- 
ried immediate symptoms and the perversion leading to remote 
effects, usually nutritional. The tendency is to gradually increase 
the quantity of dirt or other substance eaten and to proportion- 
ately decrease the amount of natural nutriment taken. The in- 
fantile type differs from that of later childhood by being much less 
severe in degree and persistency. The course of the disease is 
about one year. 



THIRST 103 

THIRST 

Increased thirst is a constant symptom of all gastric disorders, 
and is usually very marked in those in which there is much inflam- 
mation. It is the natural accompaniment of all diseases in which 
there is a rise of the body- temperature. 

It is associated with all conditions in which the body suffers 
a loss of fluid, so that one finds it in diarrhea, and especially that 
of a profuse watery type, after sweating from any cause, following 
attacks of vomiting, and when there has been a considerable loss 
of blood. The influence of habit must not be forgotten in consider- 
ing the cause, for it is more common than usually supposed. In 
diabetes insipidus and during cholera infantum the thirst is 
excessive. 



VOMITING 

The act of vomiting may be centric, toxemic, or reflex. It 
occurs during infancy with great frequency and from apparently 
slight causes, and throughout the whole period of childhood it is 
more easily excited than in the adult. This is due, in the main, 
to two facts : the natural instability of the nervous system of the 
child and the anatomical features of the stomach in the young. 

The stomach of the infant develops rapidly, especially in the 
region of the fundus, the longer curve showing the greater in- 
crease and the stomach wal s becoming rapidly more muscular. 
This rapid growth changes the position of the organ, which orig- 
inally was such as to be completely covered in front by the left 
lobe of the liver, so that at five or six months a portion of the 
organ is below the liver. The general position is somewhat more 
vertical than in later life, and the cardiac curvature is less, while 
the whole organ lies higher during the first six months than at 
any subsequent time. 

The general position, the tubular shape, and the underdevel- 
oped esophageal sphincter all tend to make vomiting easier. These 
evidences of immaturity usually persist more or less for the first 
year of life. 

For the purposes of diagnosis it is necessary that a distinction 
be made between vomiting and eructation. 

Eructation. — Eructation occurs in perfectly healthy infants, 
the returned food in the vomitus exhibiting little or no change in 
consistency or odor. Thus one knows that the act is probably a 
conservative one. It occurs without any evidence of preceding 
nausea or of any appreciable effort upon the part of the infant. 
There is no alteration in the comfort or the temper of the little 
one. It is in nearly all instances an evidence of overfeeding or 
of hasty feeding, and unless habit has already been formed, atten- 
tion to these two causative factors results in its discontinuance. 

Overfeeding is evidenced by regurgitation of the food, changed 

104 



VOMITING WITH LITTLE RISE IN TEMPERATURE 105 

but little, if at all. Too rapid feeding is easily demonstrated by 
timing the ingestion of a measured quantity. Irrespective of 
overfeeding or too rapid feeding, pressure over the infant's stom- 
ach or abdomen, or, what is just as bad, tossing and exciting the 
infant soon after feeding, will cause eructation of the food. 

The act is sometimes accompanied with facial grimaces (the 
infant seeming to go through the act of swallowing, immediately 
preceding the eructation), and if such persist, we may be sure 
that eructation is due to habit. 

Vomiting is almost always preceded by nausea, which varies 
greatly in its degree. Nausea is evidenced in infancy by restless- 
ness, facial pallor, and increased respiration ; then the act of vom- 
iting quickly follows. 

The complicated mechanism of vomiting is governed by a special 
center in the medulla, near the respiratory center, so that this 
may account for the quickened respirations accompanying the 
nausea. The act requires effort. The initiation of the act is by a 
deep inspiration, which is followed by spasmodic contraction of the 
abdominal expiratory muscles, during which the glottis is closed 
and the diaphragm is held low. The pyloric orifice is contracted 
tightly, and the cardiac orifice relaxed, the stomach itself being 
relaxed or the subject of peristaltic movements. 

It is not well to consider vomiting alone, but as it is related to 
other symptoms, and so, for the purposes of simplifying the 
diagnosis of its cause, I shall make this division of the subject : 

1. Vomiting accompanied by little or no rise in temperature. 

2. Vomiting accompanied by decided rise of temperature. 

3. Vomiting from toxemia. 

4. Vomiting associated with obstinate constipation. 

5. Diseases of the stomach with vomiting as a prominent 
symptom. 



VOMITING ACCOMPANIED BY LITTLE OR NO RISE IN TEM- 
PERATURE 

Nearly every infant acquires quickly the habit of poking its 
fingers into its mouth and frequently its success is so marked that 
the irritation of the fauces brings on vomiting as a reflex. 



Io6 VOMITING 

Habit also plays a much more important role than we are 
usually willing to admit. Following some disturbance of the 
digestive system which has excited more or less vomiting of a 
somewhat mild degree, the formation of the habit keeps up the 
frequency of the act or it may be acquired from the more common 
regurgitation of food. The lack of all evidences of preceding 
nausea and the presence of persistent facial grimaces which ac- 
company this form of food expulsion are usually pronounced 
enough to make the diagnosis easy. 

Neurotic Vomiting. — Vomiting may at times be due to some 
neurosis, but before it can reasonably be attributed to this cause, 
there must be a clear and positive exclusion of every other possi- 
ble cause. During such vomiting there is no appreciable effect 
upon the general condition or the appetite and cheerfulness of 
the child. 

Xervous diseases may have vomiting as a prominent symptom 
at their onset, and vomiting from this cause is sudden, projectile, 
and without any relation to the meals. The tongue is clean if the 
case is uncomplicated. Vomiting of this kind is frequently the 
first symptom that is encountered in brain tumor and acute or 
tubercular meningitis. 

Overdistended stomach is a very prolific cause of vomiting, 
but still more of eructation. Such vomiting is preceded by a 
more or less protracted period in which eructation is prominent 
and closely follows the ingestion of food. The vomitus contains 
the food but slightly changed, for it has not been in the stomach 
for a great length of time. Usually only a small portion of the 
meal is ejected and there are no sequelae. 

Intestinal worms may excite the act of vomiting, and the 
most characteristic thing about this- type of vomiting is that it 
occurs when the stomach is nearly empty and the taking of food 
relieves any tendency to its immediate recurrence. Of course, 
the only positive evidence of the presence of these parasites is the 
observance of them, their segments, or ova. 

Following a Coughing Spell. — Vomiting immediately following 
a spell of coughing should at once arouse a strong suspicion of the 
possibility of pertussis, and if the child is a nursling, this symptom 
alone is almost pathognomonic. As the child becomes older, 



VOMITING WITH LITTLE RISE IN TEMPERATURE 107 

however, this suspicion must be modified, as there are several 
other conditions which are likely to cause it, and these are: 

(a) Pharyngitis not uncommonly renders the mucous mem- 
branes so hyperesthetic that vomiting is very readily excited by 
the mere act of coughing. 

(b) In affections of the respiratory tract which have as an 
accompaniment the production of a thick, tenacious mucus, the 
necessary efforts put forth by the child to expel the mucus may 
easily excite vomiting. 

(c) When a child has recently suffered from pertussis and 
acquires bronchitis, the recent acquisition seems to have some 
power to bring back the tendency to vomiting which has been 
evident during the pertussis. 

In all cases of vomiting without fever one must remember the 
possibility of poisoning. The history of the ingestion of a toxic 
substance, the associated symptoms due to the action of the sub- 
stance, and the associated collapse would all help to determine the 
cause. 

In children with marked refractive errors, if the eye is suddenlv 
put to some unusual strain, or such a strain is unduly prolonged 
although not severe, vomiting associated with headache and 
rubbing of the eyes is very apt to occur. 

Vomiting occurring in the course of post-diphtheritic paralysis 
is of evil import. It is very apt to be of a violent type and per- 
sistent, and the danger is great, for it is almost invariably associ- 
ated with a greatly weakened condition of the heart and other 
signs of affection of the vagus. Occasionally such vomiting is 
the first thing to attract one's attention to the seriousness of the 
paralysis, for in many cases the paralysis is mostlv cardiac. Vom- 
iting is most apt to occur in the serious cases, and especiallv 
during those periods of acute exacerbation of the paralysis symp- 
toms, which are almost crises. Vomiting occurring within ten 
weeks of an attack of diphtheria should arouse the greatest sus- 
picion and caution. 



108 VOMITING 

VOMITING ACCOMPANIED BY DECIDED RISE OF TEMPERATURE 

In infancy vomiting occurring with a decided rise of the body- 
temperature has no distinct diagnostic value. These little ones 
are so susceptible that pyrexia, independent of its cause, is rarely 
unattended by vomiting. 

In older children this does not hold true, for frequently the 
cause of the vomiting is an error in diet at the onset of the elevation 
of temperature, and the two have therefore no connection. It is 
important that this question be decided, however, and the character 
of the vomitus would be a great aid; first, by the detection of 
particles of indigestible or undigested food; and, secondly, by the 
time at which the vomitus was expelled, in relation to the last meal, 
for this would give one a line upon the efficiency of digestion. 

With dietetic errors eliminated, sudden rise of temperature, 
accompanied or preceded by vomiting (except in infancy) , is very 
suggestive of the onset of one of the acute infectious exanthe- 
mata, and this is especially so if the act is not repeated. Of all 
the eruptive fevers, vomiting is most frequent at the onset of 
scarlet fever. (See further in this section.) If the child is three 
years or over and the eruptive diseases can be reasonably ex- 
cluded, we have still to think of the possibility of the onset of ery- 
sipelas, meningitis, peritonitis, pneumonia, and malaria. 

Cerebral vomiting is always sudden and projectile in character 
and occurs without any evidences of previous nausea. The act 
occurs as though it was the contents of the mouth being expelled 
instead of those of the stomach. Such vomiting may occur while 
the stomach is empty of food, and is most apt to occur during or 
immediately after a change of position from the horizontal to the 
vertical. The persistency is the chief characteristic of cerebral 
vomiting ; it yields to no diet or treatment and each act leaves the 
little one more and more prostrated and without that evident 
sense of relief which comes by expulsion of the stomach content 
in other types of vomiting. It is very rare that vomiting with 
these features is anything other than cerebral, but it may occur 
in other conditions, with all the characteristics of a centric origin 
except the persistency. 



VOMITING WITH DECIDED RISE IN TEMPERATURE 109 

Scarlet Fever. — In young infants the initial vomiting which 
takes place at the onset of this disease is soon accompanied by 
more or less diarrhea, which may last for one or two days. These 
two occurrences, taken together, are certainly, in young infants, 
the earliest features of the disease. After the first seven months 
there is but little difference in the onset of the disease, which 
depends upon age. The vomiting may be repeated several times 
during the first six hours and then suddenly cease, or the more 
common occurrence is one initial attack of vomiting. Within 
twelve to twenty-four hours the child complains of sore throat, 
and this is an aid in diagnosis, for while the throat may be 
markedly inflamed in other diseases which in their mode of onset 
simulate scarlet fever, there is seldom any complaint made of early 
soreness. Any child with sore throat, high temperature, and vom- 
iting suddenly appearing should be isolated until the suspicion 
of scarlet fever can be definitely determined. 

Variola. — The vomiting at the onset of variola is not a dis- 
tinctive feature, but when accompanied with high temperature 
in which the usual accompaniments of elevated temperature 
(pains in the limbs and head, restlessness, lassitude, and possibly 
delirium) are all intensified out of all proportion to the height of 
the fever, it is fairly characteristic of this disease. With a definite 
history of exposure and without protection afforded by recent 
vaccination and the lumbar pain predominating, the diagnosis 
is practically certain. 

Peritonitis. — The vomiting, which is an early occurrence, 
usually persists throughout the whole course of the disease, but in 
rarer instances may be present only at the onset. The facies and 
the abdominal symptoms generally quickly help to determine 
the diagnosis. 

Pneumonia. — The onset of lobar pneumonia is almost inva- 
riably sudden, and vomiting is one of the first and most constant 
Symptoms. Unless there has been considerable dietetic error. 
the vomiting is not continued. 

Vomiting is an early and a very severe symptom in cholera 
infantum. 



IIO VOMITING 

VOMITING FROM TOXEMIA 

The acute infections are all types of toxemia which usually 
results in the production of vomiting, but, aside from these, an 
accumulation of various toxic substances in the blood may excite 
the act of vomiting. There may be little or no rise of the tem- 
perature associated with the vomiting, or, on the other hand, 
the rise may be considerable. 

The same thing may be said in regard to accompanying pros- 
tration : it may be slight or, in young infants especially, it may be 
the only alarming feature. The uremic type may be diagnosed 
by urinalysis and the history of causative factors. All other 
types must be diagnosed by exclusion, unless there are very 
pronounced associated symptoms or a definite history to guide one 
in the determination. 

Recurrent vomiting (cyclic vomiting, lithemic vomiting, etc.) 
occurs almost exclusively during childhood, and especially in 
infancy, and a small majority of cases occur in girls. It is some- 
what more common in winter than in summer. Heredity is the 
most important predisposing cause, and a general neurotic inheri- 
tance is the rule. Other very prominent causes are constipation, 
mental overwork or excitement, and liver incompetency. 

I mention these in detail because I am convinced that it is a 
form of toxemia occurring in children who are neurotics. While 
some have claimed a purely neurotic element in the production 
of the attacks, the fact that these children are neurotics would 
readily explain the severity of the attack and also its periodic 
occurrence, when the eliminative forces have been inactive for 
a time before the onset. It is distinctly a self-limited condition 
(this is agreed by most writers), and this favors its toxemic 
instead of its neurotic causation. 

Prodromes are usually present for a few hours or even days 
preceding the attack, and the more common are flushing of the 
cheeks, coryza, nerve irritability, restless sleep, sluggishness, 
constipation, sallowness, and bad breath. Following the pro- 
dromes, vomiting occurs within six to twenty-four hours and is 
the most characteristic feature. It is usually severe at first and 
accompanied by more or less nausea. The food is expelled at 



VOMITING FROM TOXEMIA III 

first, then mucus, bile, and sometimes blood-stained mucus. The 
vomiting is repeated without apparent cause and with violent 
retching, as a rule, continuing for one or four days, then suddenly 
ceasing. 

The interval between attacks may be one month, but is more 
often three months, and all attacks are markedly similar in most 
particulars. If the child is under five years, more or less digestive 
disturbance is apt to persist between attacks. 

The diagnosis is exceedingly difficult in the first attack, but 
after one or more recurrences the diagnosis is far easier, and after 
several attacks is very plain. The first attack will usually be 
regarded as a ptomain or toxic gastritis, but intestinal symptoms 
which accompany gastritis are absent and starvation treatment 
has no effect. 

Intestinal obstruction simulates recurrent vomiting to an 
unusual degree at times, but there is absence of pain and of the 
bloody mucous stools which are generally present in the former; 
also there is no detection of any tumor. 



VOMITING ASSOCIATED WITH OBSTINATE CONSTIPATION 
Congenital malformations of the rectum are not infrequent. 
Atresia ani of a mild degree consists in a failure of invagination of 
the skin while the rectum occupies a perfectly normal position. 
In another form the rectum has been diverted in its course or has 
undergone an arrested development, so that the anal portion ends 
in a blind pouch. In more severe forms the rectum and anus may 
both be defective in their development and be considerablv sepa- 
rated. Other malformations are abnormal termination of the 
rectum in the vagina, perineum, bladder, and urethra. 

If the imperf oration is situated high up in the rectum, or if the 
obstruction is complete, no meconium is passed, the abdomen 
becomes somewhat rapidly distended, there is an unhealthy hue 
to the skin, and, later on, persistent vomiting occurs. The source 
of the trouble and also its variety are determined by thorough 
inspection. When there exists an incomplete form, which is not 
unusual, the extent and situation of such can be determined only 
by inspection combined with examination by the finger or sound, 



112 VOMITING 

Of the malformations of the small intestine, there may be 
stenosis or atresia at any part, or at many. The commonest 
situation is in the duodenum. Stenosis of the small intestine is 
not as common as atresia, and the lumen of the bowel may be com- 
pletely obliterated for a considerable distance. In such cases 
the intestine above the obstruction is markedly distended and that 
which is below is apt to be atrophied. The symptoms appear 
very soon after birth and they are simply those of intestinal 
obstruction (see index), the infant dying within one week in cases 
of atresia and within three months in cases of stenosis. 

Meckel's diverticulum is the remains of the omphalomesenteric 
duct, and is given off from the ileum, about ten or twelve inches 
above the ileocecal valve. This usually exists as a blind pouch 
(one to three inches long) communicating with the intestine. 
There may be a fibrous cord at the end of this, free in the abdominal 
cavity or attached to the umbilicus, or there may be a fecal fistula. 
Prolapse may occur, leading to abdominal tumor with a fistula 
at its summit. Such tumors are usually small, but may enlarge 
to the size of an adult fist. They are smooth, not reducible, and 
have a rosy pink surface, from which there is oozing of mucus. 
Meckel's diverticulum may compress a coil of the intestine and 
lead to an obstruction or even to strangulation, and this may occur 
in infancy or during later life. 

Malpositions are not infrequent; the ascending colon may be 
upon the left side of the abdomen. Most of the abdominal viscera 
may be transposed. The only malformations and malpositions 
which are of any practical importance are those of the lower por- 
tion of the intestine, the rest usually being incompatible with life. 

Intussusception, or invagination of the bowel, may occur at 
any age, but is far more frequent during early life. Of the 50 per 
cent, of cases occurring before the tenth year, the first year of life 
claims considerably more than half. Its frequency during early 
life is readily explained by the greater tendency to diarrheal 
disorders, to free peristaltic movement, the greater amplitude of 
the mesentery, and the mobility of the cecum. The most notice- 
able symptoms are abdominal pain, spasmodic vomiting and obsti- 
nate constipation, and the formation of a tumor. 

An acute intussusception may occur in a child who is apparently 



VOMITING WITH OBSTINATE CONSTIPATION 1 13 

in perfect health. There is a sudden attack of abdominal pain, 
which is very great and associated with repeated, violent vomiting. 
While the pain is continuous, there may be a distinct paroxysmal 
increase, and such is accompanied with much straining, screaming, 
and more or less violent kicking and tossing about. Prostration 
is always extreme. 

At first there is usually the passage of small quantities of blood 
and mucus, or sometimes these are passed with the addition of 
very small quantities of feces. Other cases show an entire absence 
of any discharge from the rectum from the beginning. Quite 
soon after the sudden onset there is usually complete and obstinate 
constipation, but a few instances are reported in which bloody 
diarrhea persisted over a considerable period. 

The most characteristic sign of the disease is the formation of a 
definite tumor which is palpable through the abdominal wall or 
by the finger in the rectum. The tumor is smooth, slightly mov- 
able, very tender, and cylindrical. In the typical cases this tumor 
is felt above the umbilicus, extending toward the right flank. 

The presence of the tumor must be demonstrated soon after the 
onset, for the rapidly occurring tympanites will, within a few hours, 
make its detection almost impossible. After the case has pro- 
gressed for twenty or more hours, rectal examination is usually 
the only means of detection. Then the tumor has usually advanced 
into the left flank, and is revealed as a congested mass with a 
central aperture (somewhat resembling the os uteri). Straining 
by the child causes this mass to advance somewhat. 

The vomiting is persistent. The vomitus consists first of the 
contents of the stomach, then of bile mixed with mucus. The 
vomiting of feces in intussusception in children is rare, for before 
this can occur they are usually dead. 

The diagnosis has to be made from all other forms of intestinal 
obstruction, and this is usually easy, if the cylindrical tumor of 
the nature described can be felt. In the absence of the tumor 
the differential diagnosis must be made from some forms of suppu- 
rative peritonitis, appendicitis, and obstruction from enlarged 
mesenteric glands, and to accomplish this it may be necessary to 
make an exploratory incision. (When this is done, it should be 
with preparation for a complete operation if conditions demand it.) 



1 14 VOMITING 

Impacted Feces. — In this condition the constipation is obstinate 
and the vomiting is not very violent or persistent. The occurrence 
of tympanites is late and collapse does not occur for several days. 
The feces can be readily felt as an impaction in the rectum. This 
impaction can be easily broken up by the finger introduced into 
the rectum, and with the removal of the mass there is an almost 
immediate relief from all the symptoms. 

Strangulated hernia as a cause of obstinate constipation asso- 
ciated with vomiting is not very difficult of diagnosis. The local 
conditions are generally so marked that there is but little chance 
for error. The hernia is irreducible (while previously it could be 
readily reduced) and rapidly becomes more tense. Added to the 
condition is that of pain upon pressure over the protrusion. The 
symptoms belonging to intestinal obstructions in general are 
present. 

The only error in diagnosis which would seem to be probable 
is that afforded by the strangulation of the testicle in the inguinal 
canal. But in this latter condition the tympanites is not marked, 
and is usually entirely absent, and examination of the scrotum 
fails to reveal the presence of the testicle in its proper position. 

Pyloric Stenosis. — The vomiting in pyloric stenosis occurs even 
when the very smallest amounts of food are taken. The vomitus 
shows constantly the absence of any bile. The constipation is, of 
course, obstinate, but this occurs with a marked depression of 
the whole abdomen and a distended epigastrium. Vomiting in 
this condition is the earliest symptom noted, beginning within 
the first three days of life, as a general rule, or it may be delayed 
for weeks. 

Usually these cases are at first treated as instances of ordinary 
gastric indigestion, but the character of the vomitus (without 
bile) should at once arouse suspicion of the true condition. After 
the case has advanced for a considerable time, the exaggerated 
peristalsis of the stomach may often be seen plainly through the 
abdominal walls. 



DISEASES OF STOMACH WITH VOMITING 115 

DISEASES OF THE STOMACH WITH VOMITING AS A PROMINENT 

SYMPTOM 

It is especially characteristic of the stomach that interference 
with its function is very liable to produce, among other symptoms, 
vomiting. The relationship between what we call functional 
disturbances and anatomical changes is not easily studied, because 
the postmortem changes are so rapid. 

Acute Gastric Indigestion. — This disease nearly always results 
from too much work having been put upon the stomach. Vom- 
iting is by far the most constant feature and occurs very early 
in the disease. The act of vomiting is excited by the food remain- 
ing for a long time in the stomach undigested. With the expulsion 
of this irritating mass the vomiting usually subsides, or, in any 
event, becomes markedly less severe. If such vomiting persists 
for more than six or seven hours, the cause is probably not one 
purely of indigestion, but of some associated disturbance. 

The temperature shows very wide variations, but, as a rule, it 
ranges between ioo° and ioi° F. ; in susceptible infants it is not 
at all unusual to encounter a temperature of 104 or 105 F. 
One characteristic of the temperature, irrespective of its height, 
is that it rapidly approaches the normal as the stomach is emptied, 
and in this particular temperature and vomiting keep pace. 

In a few instances there are more or less decided nervous 
symptoms (as restlessness, stupor, headache, and rarely convul- 
sions), but these are usually very mild. The course of the disease 
is about forty-eight hours, but rapidly occurring relapses are 
common — so much so as to be almost the rule. In infancy there 
is a marked tendency of the disturbance to extend to the intes- 
tines, and the diarrhea with stools showing the presence of undi- 
gested food, which so frequently occurs, is an evidence of such 
extension. 

The diagnosis is made principally by the short duration, the 
character of the vomitus, and the relief which comes from the 
emptying of the stomach ; also the marked tendency to relapse. 
From acute gastritis a diagnosis is at first impossible, unless 
there is a history of similar previous attacks and an exclusion of 
the etiologic factors of gastritis. Persistence of all the symp- 



Il6 VOMITING 

toms, and especially those of pain, vomiting, fever, and thirst, 
indicates the inflammatory element and suggests gastritis, and 
if the vomitus contains mucus tinged with blood, the diagnosis 
is practically positive. In questions of doubt one would naturally 
lean strongly toward a diagnosis of indigestion, for it is so common, 
while gastritis is comparatively rare in infancy and scarcely ever 
exists alone. 

Acute Gastritis. — As has been previously stated, the onset of 
this disease can hardly be distinguished from acute indigestion. 
However, within six or seven hours, when one naturally expects 
the vomiting caused by acute indigestion to cease, or at least to 
markedly subside, there is no let up, and vomiting, temperature, 
and pain all remain about as severe as at first. When this occurs, 
it should arouse a suspicion of an inflammatory element. 

The vomitus about this time will become pale in color, sometimes 
mixed with bile, and is sour ; if mucus is present, which is streaked 
with blood, the diagnosis is reasonably certain. The thirst at this 
stage begins to be intense, and attempts to relieve it by the inges- 
tion of fluids lead to their immediate and violent expulsion. This 
is a suspicious sign of inflammation. 

Inspection usually shows at this time a slight pufnness of the 
epigastrium ; upon palpation the region seems somewhat hard and 
tumefied. Tenderness is more or less marked, and after a few 
hours tends to extend to the abdomen. If the temperature is 
at all high, it is only so for the first twenty-four hours, and after 
that it is rare for it to exceed ioi° F. 

From the very onset the symptoms are very apt to be severe. 

Preceding the attack there is usually constipation, which may 
give way to diarrhea. The urine is high colored, the respirations 
shallow and frequent, and the pulse rapid and weak. 

If diarrhea is added to the symptoms to any considerable extent, 
it indicates an extension of the disturbance to the duodenum 
and small intestine. The course of the disease is usually from 
four to eight days, although if not properly cared for, it may 
persist for three weeks. 

The above describes the usual form of the disease — acute catar- 
rhal gastritis ; but mention must be made of the rarer forms. 

Croupous gastritis is practically a curiosity, and the diagnosis 



DISEASES OF STOMACH WITH VOMITING 117 

is never made during life, unless a piece of the membrane is 
vomited. Generally it is a sequela to croupous inflammation of 
the pharynx, intestines, or esophagus, and the symptoms of the 
primary disease completely cover the gastritis. 

Toxic gastritis results from the local action of irritants ot a. 
poisonous nature, so that for their diagnosis there must be the 
history of the ingestion of some such substance (this may be intro- 
duced by the sucking of painted toys, matches, etc.). 

Suppurative gastritis has as its feature infiltrations of pus in 
the connective tissue of the stomach. It is recognized only at the 
autopsy. 

Gastroduodenitis. — Inflammation of the duodenum may exist 
alone, but usually this is not so, for in most instances we find 
the stomach and duodenum in associated inflammation. So, 
then, the term gastroduodenitis seems to be the best one. How- 
ever, inflammation of the duodenum may be associated with in- 
flammation of the common bile-duct or, again, with the rest of the 
small intestine. 

At its onset this disease (like acute gastritis) cannot be well 
distinguished from acute indigestion. Generally the first sign 
which will guide us in the diagnosis is the site of the pain. Pain is 
usually quite marked and localized somewhat definitely in the 
region of the duodenum. There is usually some associated 
tenderness also. The vomiting is generally very persistent for 
several days, and this would help to exclude the probability of 
acute indigestion. 

Constipation is generally present. The persistence of the 
symptoms after the first seven hours would lead one to suspect 
gastritis, but although most of the symptoms are similar, the 
prostration is not so marked in gastroduodenitis. Nevertheless 
it is usually not until the third day of the disease that we have 
the appearance of the first symptom of real diagnostic value; 
this is icterus. The conjunctiva is the first situation affected, 
then the skin. With the onset of the icterus we have added the 
symptoms of an obstructive jaundice: gray or white stools, intes- 
tinal flatus, dark yellowish-green or bronze-colored urine. Itching 
of the skin and slow pulse, which are so common during- jaundice 
in the adult, are very rare among children. The general symptoms 



Il8 VOMITING 

persist for about two weeks, but the jaundice may remain for 
several days longer, gradually subsiding. 

Chronic Gastric Indigestion; Gastric Catarrh; Chronic 
Gastritis. — Clinically, all these diseases are so nearly identical 
that there is no practical advantage in considering them separately. 
Taking them collectively, the chief difference in their sympto- 
matology is determined by the age of the child. 

In infancy the one constant characteristic of all three is the 
vomiting. This takes place without regard to the time of the 
ingestion of food, some infants vomiting soon after the meal, 
while others vomit at protracted intervals. The vomitus consists 
of food (often that which has been in the stomach for seven or 
eight hours) and large quantities (often an ounce) of mucus. The 
stomach retains the food several hours longer than is normal, 
and this is well illustrated by stomach-washing. The failure of 
digestion is attested by the presence of undigested food in the 
stools. 

As a general thing, anorexia is very marked and the tongue is 
heavily coated. Of course, signs of general malnutrition are 
always present (anemia, restlessness, loss of weight, arrested 
development, etc.), and there is some bowel derangement , usually 
diarrhea. Low toxic symptoms are not uncommon, affecting both 
physical and mental development. The diseases run an indef- 
inite course, with little tendency to spontaneous recovery. 

In older children vomiting is still the characteristic symptom, 
but it is not so persistent or so frequent as in infancy. It generally 
occurs shortly after one or more of the meals. Between the attacks 
of vomiting there is apt to be considerable regurgitation of small 
particles of food and an acid fluid. The appetite is very fickle 
and there may be epigastric tenderness. Malnutrition with its 
host of consequent symptoms completes the symptomatology. 
Generally it is possible to demonstrate a slight degree of dilatation. 
On account of the relaxed and congested condition of the mucous 
membranes of the throat, there is apt to be an obstinate cough. 

Dilatation of the Stomach. — So long as the motility of the 
stomach is but slightly affected, there are few consequences ; but 
should the lack of action be so pronounced that particles of food re- 
main constantly in the organ, fermentation results, which tends to 



CHARACTER OF THE VOMITUS 119 

distend the muscle; thus dilatation may be produced. Usually 
motor insufficiency and dilatation are associated, but this is not 
essential. Dilatation may arise from a variety of causes, as mechan- 
ical stenosis of the pylorus, anomalies in form and position of the 
organ, fermentation, and atony. 

Dilatation is commonly seen during infancy, as a somewhat 
temporary feature of all the gastric derangements. Permanent 
dilatation usually follows repeated attacks of these disorders. 
The only reasonable way to diagnose such a condition is by 
percussion, filling the organ with gas or fluid not being justifiable 
in infancy. If percussion is carefully performed two or three 
hours after a meal, one can generally demonstrate a tympanitic 
note extending down to, or even below, the umbilicus. In older 
children this may be corroborated by filling the stomach with 
fluid and again percussing over the same area which has been pre- 
viously marked. 

Dilatation of the transverse colon may be mistaken for dila- 
tation of the stomach, but in the former the lower outline is slightly 
concave, while in the latter it is strongly convex. Degrees of 
dilatation are determined by using measured quantities of fluid 
in the stomach. 

CHARACTER OF THE VOMITUS 

Blood. — The blood may be simply streaked through the 
vomitus or it may compose the greater part of it. The first con- 
sideration would naturally be to determine beyond all possibility 
of doubt that blood is actually present in the vomitus, and it is 
easy to be deceived in this regard. There are several articles 
which, ingested, cause vomiting and exhibit a vomitus which is 
deceptive, so that in every case where there is the remotest chance 
for doubt, an examination should be made by the microscope to 
determine the presence of blood-corpuscles. 

Having determined that blood is actually present in the vomitus, 
there remains still another element of doubt : Does the blood come 
from the stomach? That is, a false condition must not be con- 
founded with a true hematemesis. In the course of the former 
the amount of blood in the vomitus is usually small, sc^ that there 
are no associated general symptoms depending upon the amount 



120 VOMITING 

of the hemorrhage, and its source is generally easily discovered. 
In the latter (true hematemesis) constitutional symptoms are 
almost invariably associated and the child's health has suffered 
in proportion to the severity and persistency of the trouble. 

The most frequent cause of the false condition is epistaxis, and 
this is especially true of older children. If nose-bleed occurs while 
the child is in the prone position, the blood is very apt to be 
swallowed and subsequently vomited. The nose should be 
examined to determine the possible source of the hemorrhage, 
and if from the nose, clotted blood will readily be detected. If 
any cause within the nose is excluded, then the possibility of an 
acute esophagitis must be determined. 

It is somewhat rare that a fissured nipple is the source of the 
blood which an infant may vomit, for such blood is seldom swal- 
lowed, but still it is a possibility which must be remembered. It 
is quite common that the violence of an attack of vomiting will 
cause some blood to be streaked through the vomitus. In debili- 
tated children of all ages there may be a general lack of tone to all 
of the mucous membranes, and the stomach does not escape, so 
that hemorrhage may occur from very slight causes. 

Hematemesis is not a usual occurrence in young children, because 
the common causes of hemorrhage from the stomach do not exist 
so generally in that period of life. In older children the most 
common cause of hematemesis is purpura hemorrhagica, and the 
clinical picture of this disease is so marked that there would be no 
probability of any error arising as to the cause of the hemorrhage. 

Occasionally blood is vomited during the course of scurvy, but 
when it occurs, it is at a stage of the disease in which the cause is 
easily recognized. Ulcers of the stomach are rare in childhood, 
and when they occur, the symptoms are rather indefinite. Before 
perforation occurs, about the only symptoms present are gastric 
pain and tenderness, bloody stools, and the vomiting of blood. 
Rubeola and variola of the hemorrhagic types often have vomiting 
of blood as an early symptom, and the diagnosis must be made 
by a consideration of all of the diagnostic points of the disease 
with which the hemorrhages are associated. 

Hemorrhagic disease of the newly born has as its marked fea- 
ture hemorrhages from various organs and tissues, and the stomach 



CHARACTER OF THE VOMITUS 121 

is no exception to the involvement. Hemorrhages take place, 
as a rule, about the third day of life, and in no instance later than 
the twelfth. General malnutrition and hereditary syphilis tend 
to promote hemorrhage from any mucous membrane from slight 
causes, so that they may be responsible for hematemesis. 

Food. — The food taken is usually vomited after several feedings 
in cases of acute inanition and dilatation of the stomach. The 
vomiting which occurs in pyloric stenosis is usually within a very 
short time of the meal and the food is unchanged; bile is absent. 
Vomiting of the food, which is but partly digested and is very 
sour, occurs in acute gastritis more often than in other conditions. 
Ejection of the food directly after a coughing spell points to per- 
tussis, or in rarer instances may be due to the violence of the 
coughing. 

Uncoagulated Milk. — The return of uncoagulated milk from 
the stomach of infants may be due to the formation of a vomiting 
habit, and if so, is apt to be accompanied by facial grimaces. 
The more common causes are violent motion at any time within 
twenty minutes of the meal or pressure over the abdomen. Over- 
feeding is a prolific cause of such vomitus appearing. 

If the food has been retained for over twenty minutes and is 
then returned uncoagulated, it is evidence of a lack of sufficient 
acid in the stomach; if hyperacidity is present, coagulated milk 
will be expelled quickly after its ingestion. In marasmus the milk 
(or other food) is vomited almost as soon as it has been taken. 

Food and Mucus. — In determining that mucus from the stom- 
ach is present in the vomitus care must be taken to exclude the 
swallowing of mucus and its subsequent ejection with the food. 
Mucus is most apt to be vomited with the food in dilatation of the 
stomach and chronic gastric indigestion, gastric catarrh, chronic 
gastritis, in the last three of which the amount of mucus is usually 
very large. In infancy the amount may be one ounce. 

Food and Bile. — In acute intussusception the contents of the 
stomach are first violently ejected, and this is followed very shortly 
by the vomiting of bile. Fecal vomiting is rare in childhood. 

Pus. — Pus may be vomited as the result of swallowing the con 
tents of an abscess, and this should be thought of at once. 

Membrane. — When a membrane is vomited, it should at once 



122 VOMITING 

be examined microscopically to determine its nature. One must, 
of necessity, exclude the possibility of the swallowing of a mem- 
brane from an existing acute esophagitis. Croupous gastritis 
may be the source of the membrane, and vomiting of a membrane 
is the only thing which happens during life to aid us in the diag- 
nosis of the disease. This disease is so rare that it is practically 
a curiosity. 

HEMORRHAGE FROM THE STOMACH 

The most common variety of hemorrhage from the stomach is 
that which is seen in the newly born and which is the result of 
hemorrhagic disease of the newly born. Such hemorrhage 
begins during the first three days of life, as a rule, and never after 
the twelfth day. 

When the blood is vomited, its appearance depends upon the 
length of time that it has remained in the stomach, bright red 
blood indicating a very recent hemorrhage, and the vomiting of 
dark-brown masses, which is the usual occurrence, indicating 
more remote bleeding. The quantity varies from very small 
amounts up to one ounce. 

In debilitated children of all ages the mucous membrane of the 
stomach may become eroded and result in the vomiting of blood 
or blood-streaked mucus. Autopsy is the only means of deter- 
mining the existence of this cause of bloody vomiting. 

Hematemesis may occur in hemophilia, purpura, or scurvy, 
and occasionally it occurs during the course of hemorrhagic 
rubeola and hemorrhagic variola. 

There may be no symptoms except those of an internal hemor- 
rhage, but that is exceedingly rare. The mere presence of the 
blood in the stomach almost invariably excites vomiting, so that 
to avoid repetition the causes and diagnosis are considered in 
detail in the section on "Character of the Vomitus." The object 
of this short section is to impress the fact that, although rare, hem- 
orrhage may occur without vomiting. 



ABDOMINAL PAIN 

It requires considerable judgment to give abdominal pain in 
the child its proper significance. In the examination of the older 
child it is necessary to determine at the outset whether or not the 
pain is limited to the abdominal wall, or if it is associated with one 
of the underlying viscera. 

While it is not very common, at the same time it is not infrequent 
that we find the wall of the abdomen hyperesthesic. The result 
is that in the examination to determine the site of any abdominal 
pain the inner aspect of the thighs should be first examined. In 
doing this we gain two things : first, we do not directly approach 
the site of expressed pain, and we thereby gain the child's con- 
fidence somewhat; and, second, hyperesthesia of the abdominal 
wall is almost invariably associated with a similar condition of the 
inner aspect of the thighs, and absence in this situation would 
lead one to suspect its absence in the abdomen. 

When such hyperesthesia is present, it is spread over a somewhat 
considerable area, extending well up over the chest. If a fold 
of the skin is grasped and firm pressure is made upon it, the pain 
is increased in proportion to the degree of pressure. Hyperesthesia 
of the skin of the abdomen is fairly constantly associated with 
typhoid fever and meningitis; less frequently with malaria, the 
acute infectious diseases, and anemia. 

Sometimes we find that the pain is simply muscular, and the 
causes of such a condition are usually exposure to cold, straining 
from violent coughing, unusual exercises involving the abdominal 
musculature, and in rare instances rheumatism. In all such cases 
the pain is localized quite strictly to the recti muscles if the active 
cause is a mild one. 

However, if the condition is of the unusual severe type, there 
may be vomiting, some fever, and rather wide-spread abdominal 
pain, which compels the child to assume one position and remain 



124 



ABDOMINAL PAIN 



in it. The whole course of the severest attacks is not over forty- 
eight hours. In nearly every instance exercise is the cause of the 
severe attacks. 

If the pain is due to inflammation of the peritoneum, it is by far 
the most acute abdominal pain which is observed. It is contin- 
uous, although this fact may be overlooked, owing to the acute 
exacerbations which occur and which are due to peristalsis. 
Associated with the pain there is tension of the abdominal wall, 
the slightest pressure increases the pain markedly, and there are 

the other evidences of in- 
flammation of the periton- 
eum, as tympanites, constipa- 
tion, etc. 

Intestinal Colic. — This is 
one of the most frequent 
causes of pain and crying in 
infants. They not only cry, 
but usually there is a succes- 
sion of shrieks, which is asso- 
ciated with throwing about of 
the legs, until relief comes with 
the expulsion of flatus. Gen- 
erally such attacks are asso- 
ciated with constipation, but 
this is not always the case, 
as they not infrequently are 
associated with diarrhea. A 
valued aid in the rapid recog- 
nition cf this condition is the 
fact of the quick relief which 
is afforded by the use of a warm enema. 

By far the chief seat of conditions which result in attacks of 
intestinal colic is the stomach, and failure of perfect digestion in 
that organ is almost certain to be followed by colic. Intestinal 
parasites are a less frequent cause, as is also loss of tone of the 
muscular walls of the intestines. 

The abdomen is generally much distended with gas, and if there 
is an absence of this feature, the search for the cause should be 




Fig. 22. — Abdominal pain, general and 
colicky. Indicative of intestinal colic, intes- 
tinal obstruction, intestinal perforation, the 
onset of appendicitis, peritonitis, vertebral dis- 
ease, pneumonia (frequently prominent), rheu- 
matism of abdominal muscles, overexertion. 



INTESTINAL COLIC 1 25 

most thorough, and it ought not to be accepted as a simple intes- 
tinal colic until every other possible cause is excluded. It is 
characteristic of the condition that after the subsidence of the 
attack there is an entire absence of all ill effects. 

Intestinal colic is most frequent during the first six months of 
life, and irrespective of the fact as to whether the infant is breast- 
fed or bottle-fed. Perhaps it would be no exaggeration to say that 
fully three-quarters of all the cases are due to the proteid ele- 
ment in the food. 

In the diagnosis of the condition one must be certain that the 
attacks are acute, for a chronic state of flatulence in an infant 
may be associated with more or less wasting and slight fever, 
and would suggest the probability of a beginning tuberculous 




Fig. 23.— Palpating the appendix. 

peritonitis. If there is an elevation of the evening temperature 
and a well-defined tenderness of the abdomen, with various points 
at which there is evident thickening, then the diagnosis of tuber- 
culous peritonitis is almost certain. 

Appendicitis. — There are three cardinal symptoms of this 
disease — localized abdominal pain, localized abdominal tenderness, 
and rigidity of the right recti muscles. 

Of the three, the first is the least important in diagnosis, for it 
may be slight. Usually, however, pain is severe and intermittent, 
so that the child complains as of colic. The child (unless of much 
intelligence and over six or seven years of age) exhibits its usual 
inability to definitely locate the pain, and in most instances when 
it is somewhat definitelv located, it is referred to the umbilicus. 



126 ABDOMINAL PAIN 

Tenderness is a much more constant feature and is seldom, if ever, 
absent. By palpation it is located in the right inguinal region, 
but the whole abdomen may be hyperesthesic. Even in this 
case there is more acute tenderness in the right inguinal region. 

Muscular rigidity is the last-mentioned and yet the most valua- 
ble sign of the three, for it is never wanting in some degree. It is 
particularly marked in the lower quadrant on the right side. 

Rise of temperature may be moderate or there may be consid- 
erable pyrexia, the usual ranges being between ioo° and 104 F. 
It must be remembered, however, that the height of the fever is 
no indication of the severity of the disease. Associated with the 
fever there is generally more or less vomiting, which is usually 
repeated, and may persist until it becomes first bilious, then 
fecal (the latter being very rare). 

In contrast to the usually low temperature, the pulse is charac- 
teristically rapid and is often thin and thready. Thirst, which 
is marked, and constipation, which is obstinate, are the rule, although 
the attack may at times be preceded by diarrhea. The child 
usually assumes a dorsal position with the right limb flexed at 
the hip and the knee. The termination of the disease is by 
resolution, the development of general peritonitis, or the forma- 
tion of an abscess. 

An attack of appendicitis is usually sudden, and the acute 
catarrhal type may subside within forty-eight hours and fail to 
be recognized. However, if all cases of supposed acute attacks 
of indigestion were examined after a subsidence of all symptoms, 
in many instances a careful palpation would reveal a slight 
thickening and induration about the region of the appendix, and 
the true nature of the attacks would thus be discovered. 

It is not unusual for several such attacks to occur within a few 
months or years, and in every instance be attributed to some 
error in diet. The value in recognizing such attacks is in advising 
appropriate measures for the prevention of a severe suppurative 
form of the disease, which is liable to appear at any time, either 
during the course of one of the mild attacks or directly after it. 

If an abscess is formed, then this is recognized by the boggy 
feel of the tumor and exploration by the fingers through the rec- 
tum, or in rare instances it may be justifiable to use the exploring 



APPENDICITIS 127 

needle to aspirate the pus. Symptoms which are strongly sug- 
gestive of an abscess are fluctuating fever (with the history of 
chills in older children), a persistently coated and furred tongue, 
and increasing prostration. 

The value of a blood-count is doubtful in children. Such a 
count requires the most careful technic, and to avoid error there 
must be several counts daily, and if the pus become encysted, 
the count is of lessened value. For practical general work it is 
useless. 

When an abscess has developed, the course of such is very 
indefinite, sometimes persisting with symptoms of a mild septi- 
cemia for weeks. It is very rare that severe symptoms are 
persistent for a considerable period. Peritonitis sometimes will 
develop upon the third or fourth day, and usually collapse and 
death quickly follow in such cases. 

The symptoms which are most suggestive of such an extension 
are an otherwise unexplained rise in the temperature, abdominal 
distention, rather sudden subsidence of the localized pain, to be 
followed shortly by generalized abdominal pain, tympanites, and 
collapse. 

The diagnosis must be made first from acute indigestion, which 
usually exhibits a higher temperature and much more rapid sub- 
sidence of the acute symptoms, and which exhibits no thickening 
in the region of the appendix when palpation is later practised. 

From volvulus and intussusception the diagnosis is usually 
readily made, for in these conditions there is absence of the 
temperature rise, and there is present the passage of bloody stools 
or mucous discharges from the rectum which are accompanied 
with tenesmus and the development of a left-sided tumor, as a 
rule. The tympanites may be so early in appearance and so 
marked in degree that the tumor cannot be made out. 

Nephritic colic may simulate appendicitis for a time, but the 
pain is limited to the lumbar region, and instead of increasing 
is decreased by pressure. The pain generally radiates along the 
course of the ureter and is relieved to an extent by urination. 
There is no muscular rigidity of the abdomen. Slight fever 
may be present, but this is unusual. 

Hepatic colic sometimes has a most acute onset with seveie 



128 ABDOMINAL PAIN 

pain and vomiting and may simulate appendicitis, but the pain 
is more severe and persistent in character and confined mostly 
to the lower portion of the right side of the chest. Typhoid fever 
is sometimes hard to differentiate, particularly when the history 
is vague and the symptoms are not pronounced. It is then 
necessary to delay judgment or apply the Widal test. 

Pneumonia of the right lower lobe may have an onset much like 
appendicitis, and with a similar abdominal pain, which is due to 
involvement of the lower dorsal nerves, so that it is necessary to 
carefully examine the chest to distinguish the real disease. The 
symptoms which would suggest a lung condition are: sudden 
rise of temperature to 103 F. or over and its maintenance about 
that point, increased respirations (out of proportion to pulse), 
relaxed abdominal muscles, and cough. 

Acute Peritonitis. — This disease is usually easy to recognize, 
on account of the well-defined symptoms, chief of which is severe 
and diffused abdominal pain. This pain is increased by the 
slightest degree of pressure, so that the motion of the child, cough- 
ing, sneezing, or jarring the bed will increase the suffering greatly. 
The result is that the child remains immobile upon the back 
with the legs drawn up to relieve the tension on the abdominal 
muscles. 

The onset is nearly always quite abrupt, with vomiting and 
rise of temperature, the vomiting being usually present only at 
the onset and the temperature reaching 103 or 105 F. The 
most constant feature of the disease is the swollen and tympanitic 
abdomen. The distention is diffuse in nearly every instance, 
but rarely it may not be so regular. Constipation is the rule. 

Outside of the local symptoms, there is evidence, from the 
general ones, of the seriousness of the disease. From the very 
start prostration is very marked and the pulse is weak and small. 
The pain is evidenced by the drawn and pinched features, and the 
extremities are in some cases cold and clammy. The mind is 
usually clear. When the vomiting persists, it is generally an 
indication that collapse will quickly supervene. 

In childhood the course of the disease is usually rapid (three or 
four days), but if of a moderate severity, the course may be ten 
days, and after that time there is generally a localization of the 



CAUSES OF COLIC 1 29 

process with good chances for recovery. If peritoneal abscess 
develops, then we have the added symptoms of hectic tempera- 
ture, chills, sweating, and local signs of tumor. 

In young infants the disease is not so well defined and there- 
fore is harder to distinguish. In them it usually proves fatal 
within the first seventy-two hours, and with symptoms so obscure 
that often the diagnosis is not made. The pain is evidenced by 
the restlessness, the constant crying, and fretfulness. In most 
cases the diagnosis is not made unless there has been a clear 
history of some etiologic factor. In the newly born this might 
be by direct infection through the umbilical vessels; in older 
infants by traumatism, severe burns, or as a secondary condition 
to appendicitis, hepatic abscess, acute intestinal obstruction, 
pleuritis, gonorrheal vulvovaginitis, pneumonia, or scarlet fever. 

Catarrh of the Small Intestine. — This may produce colic, 
and if so, the pain usually immediately precedes a diarrheal stool 
and relief is coincident with the movement. 

Catarrh of the large intestine is accompanied by frequent 
colicky pains which are associated with tenesmus and stools 
which are composed mostly of mucus. 

Intussusception exhibits a most intense abdominal pain, and 
this is discussed on page 113. 

Intestinal Parasites. — These may be suspected as the cause 
of colic if the pain occur early in the day upon an empty stomach, 
but the only positive diagnosis is made by their removal resulting 
in an entire subsidence of all the symptoms. 

Spinal Caries. — The pain is usually worse at night and is 
referred to those parts of the abdomen which are the site of the 
distribution of the nerves which are nearest the site of the spinal 
lesion. 

Nephritic Colic. — There is usually a distinct family history or 
history of previous attacks, and it follows exercise, as a rule. 



EXAMINATION OF THE ABDOMEN 

Inspection. — This should note, first of all, the general condition 
of the abdominal wall. Thin walls are due to absence of adipose 
tissue or to deficient muscular development, and are associated 
with conditions of malnutrition or those which cause intra-abdom- 
inal pressure. On the other hand, a thickened abdominal wall 
is due to edema or to excess of adipose tissue. 

The skin should be smooth and of a color corresponding to the 
rest of the covered portions of the body (except about the navel , 




Fig. 24. — Rectal bimanual examination. Finger of one hand is introduced well up into the 
rectum, while the other hand is free to manipulate the lower abdomen. 



where it is slightly darker) and the superficial veins should not be 
prominent. If veins are prominent, it indicates some interference 
with free circulation in the inferior vena cava. 

The navel should be entirely healed in infants within two weeks 
of birth, and should not show any signs of inflammation. As a 
rule, the remnants of the cord separate on the fifth day, and 
separation occurs without appreciable odor (which, if present, 
indicates infection). Bleeding from the navel may be of two 
kinds : it may be due to a poorly adjusted ligature or to a consti- 

130 



INSPECTION OF ABDOMEN 



131 



tutional condition, as hemophilia, hereditary syphilis, or the 
hemorrhagic disease of the newly born. In all these conditions, 
which are general, there is associated hemorrhage from other 
organs and parts of the body, and the diagnosis of each must be 
made by the consideration of all accompanying symptoms. 

Protrusion of the navel may be due to superabundant skin (in 
which case the protrusion is conical and irreducible) or may be 
due to hernia, and if the latter, then the shape is somewhat spheri- 
cal (unless the protrusion is large, when it may be conical), the 
size is increased by crying, 
and the tumor is readily 
reduced. Rarely we en- 
counter the umbilicus 
fungus, which is about the 
size of a small pea, is 
pediculated, and bleeds 
readily under the slightest 
interference, being readily 
recognized by these quali- 
ties. 

Respiratory movements 
must be noted, and their 
absence suggests some pain- 
ful condition in the abdo- 
men, if collapse be ex- 
cluded. Rigidity usually 
accompanies painful condi- 
tions. The movements are 
exaggerated in most condi- 
tions which cause an inter- 
ference with free respiration, and respiratory retraction of the 
abdomen is usually very marked in laryngeal stenosis. 

Under normal conditions the wall of the abdomen seems to be 
upon a level with the lower wall of the chest when the child is in 
a recumbent position. If below that level, then the abdomen may 
be said to be retracted, but this condition is of slight diagnostic 
value unless associated with other symptoms, for it occurs in 
conditions in which there is much body waste, and especially 




Fig. 25. — The abdominal regions. The heavy 
line at the upper border shows the extreme limit 
of the diaphragm. Imaginary lines divide the ab- 
domen into different regions which, for the sake of 
clearness and precision, are known as the right and 
left hypochondriac, the epigastric, the right and 
left lumbar, the umbilical, the right and left in- 
guinal, the hypogastric. 



132 EXAMINATION OF THE ABDOMEN 

during those diseases in which vomiting and diarrhea are persistent. 
A retracted abdomen associated with constipation and fever of a 
typhoid type is at once suggestive of tuberculous meningitis, and 
if, in addition, the fever is low and the child somnolent, the diagno- 
sis is almost certain. 

Omphalitis. — This may develop in three days after birth or may 
be delayed for as many weeks. The tissues about the umbilicus 
become first reddened, then swollen and painful, and there may be 
added some slight constitutional symptoms (which latter indicate 
that the inflammation has involved the umbilical vessels). The 
condition may remain localized, or spread and result in general 
sepsis. 

Palpation. — This procedure must be very gently performed, 




Fig. 26. — Examination of the abdomen by one hand reinforcing the other. Such an examina- 
tion is rarely necessary during childhood. 

and with the warmed hand until the child's confidence is somewhat 
gained, then the examination may be more firm, but still gentle. 
Palpation should be made by performing circular movements 
over the part to be examined, and while this is being done, the 
child's attention should be diverted from the examination as 
much as possible. This is best accomplished by a story, for the 
usual method of using a toy generally results in muscular effort, 
which is undesirable, and when such effort involves the abdominal 
musculature, the object of the diversion, of course, is defeated. 
A change of position, and especially flexure of the legs, will aid 
in securing an increased degree of relaxation. 

The method of reinforced pressure (one hand aiding the other), 
which is so useful in adults, is rarelv necessarv in the examination 



ENLARGEMENT OF THE ABDOMEN I 33 

of children, and the same might be said of the use of anesthetics 
to secure relaxation; it is rarely needed. Normally, the child's 
abdomen has the feel of an elastic cushion which is moderately 
inflated with air, but there is one exception to this, and that is 
during the first month of life, when the liver and spleen are readily 
palpated. 

In performing palpation of the viscera it is well to remember 
that it is much easier to palpate the border of an organ than its 
surface. So, then, in palpating the abdominal viscera, it is best 
to begin a little below the organ and palpate upward during 
inspiration, if possible. 

ENLARGEMENT OF THE ABDOMEN 

The size of the abdomen varies in different children, and this is 
due partly to the amount of adipose tissue present, partly to the 
size of the intestines and the age of the child. In infants and 
young children the abdomen is slightly more protuberant than in 
later life. However, allowing for these differences, enlarged abdo- 
men may be said to exist if, while the child is recumbent upon a 
fairly firm surface, the abdominal wall lies above the level of the 
lower wall of the chest. This is simply a general statement, and 
allowance must be made in the case of thin children, for in that in- 
stance one would not expect the level of the abdomen and the 
lower chest wall to correspond; the abdominal wall would be 
slightly below the chest level. 

The best way to determine the cause of the enlargement would 
be to first of all eliminate both of the most frequent causes of 
enlarged abdomen in children, and these are tympanites and 
ascites. 

Tympanites. — This may have one of two ways of developing — 
acutely or chronically. 

Acute development with moderate distention occurs very 
frequently during infancy, and is in most instances due to acute 
catarrh of the small intestines, gastric or intestinal indigestion, or 
constipation. It is commonly associated with all the diseases of 
infancy in which the digestive conditions are at all disturbed. 

The acute form with marked distention has an entirely different 



134 EXAMINATION OF THE ABDOMEN 

meaning, and is usually associated with the more serious diseases 
of children. It is a part of the symptom group in peritonitis, 
intussusception, and intestinal obstruction from any cause. 

Chronic tympanites is usually present in all the chronic 
intestinal disorders to a greater or less degree, and there are quite 
distinct periods of exacerbation. Occurring in rachitis and 
marasmus, the tympanites is much more constant, while in chronic 
peritonitis the course is progressive. 

In children with poorly developed muscles the degree of tym- 
panites which may occur from any given cause is greater than 
occurs in children whose general musculature is well developed. 
It is not difficult to recognize enlargement due to tympanites, 
because the abdomen is tympanitic everywhere upon percussion. 




Fig. 27. — Testing for fluid in the abdominal cavity. 

If the abdominal wall is very tense, then the tympanitic note is 
more marked and the area is enlarged. 

Ascites. — This is an accumulation of fluid in the peritoneal 
cavity, and if it is large and rapidly developed, the abdomen is 
barrel- shaped and change of position does not alter its shape; but 
if the development is slow and the accumulation less large, the 
abdomen is flattened at the top and bulging at the sides when the 
child is recumbent. If the position is changed, the shape of the 
abdomen also is altered. In an uncomplicated ascites the surface 
of the abdomen is smooth. 

Upon palpation fluctuation is detected if the following procedure 
is observed: Place the left hand firmly against one side of the 



ENLARGEMENT OF THE ABDOMEN 



135 



abdomen, and with the right hand the abdomen is lightly tapped on 
the side opposite to the left hand. The best points are at the 




Fig. 28. -Illustrating the lateral dull areas and the central tympanitic area which is evident 
when the abdomen contains free fluid. 



level of the fluid, and to determine this it is well to commence low 
down and work upward toward the median line. If the abdomen 



TYMPANITIC 



DULL 




Fig. 29.— Diagram illustrating bilateral flank dullness when free fluid is in the abdomen and 
the child is in a dorsal posture. 



is very tense from gas, false fluctuation may be obtained, but this 
is differentiated by the very small wave which is produced in a 
very tense abdomen. Percussion gives dullness over the site of 



i 3 6 



EXAMINATION OF THE ABDOMEN 



the fluid, and naturally a change of position resulting in a change 
in the situation of the fluid causes the dullness to vary. 

The subjective symptoms are due to mechanical pressure, plus 
those which are dependent upon the cause of the ascites. It is 
quite important that ascites should not be confounded with the 
conditions which cause accumulation of fluid in organs or sacs, as 
is observed in hydronephrosis, distended bladder, or ovarian cyst. 

Hydronephrosis. — This is due to some obstruction to the free 
flow of the urine, either in the ureter, the bladder, or the urethra, 
and the resulting distention of the ureter or renal pelvis. It may 
be unilateral or bilateral, congenital or acquired. It is not 
necessary for its production that the retention of the urine be 



TYMPANITIC 




DULL 



Fig. 30. — Diagram illustrating that when free fluid is in the abdomen, a laterodorsal 
posture results in the upper flank being tympanitic, while the area of dullness in the lower 
flank is increased. 

complete, for the amount or degree of retention depends largely 
upon the nature of the obstruction. Usually there is a distention 
of the whole of the urinary tract above the site of the obstruction. 
The symptoms (other than tumor) are exceedingly variable and 
may be absent, so that the diagnosis is generally made from the 
presence of an abdominal tumor. This tumor is spherical, fluc- 
tuating, and smooth, and intimately connected with the kidney. 
If the tumor is unilateral, then the diagnosis is comparatively 
easy, for there is unilateral bulging and flatness upon percussion, 
and the connection with the kidney can usually be well mapped 
out ; but if bilateral, then the diagnosis is not easy. Puncture 
yields a transparent fluid which contains urea and uric acid. 



ENLARGEMENT OF THE ABDOMEN 



137 




There is a rare condition which may closely simulate hydro- 
nephrosis, and that is the tumor which is sometimes seen in echi- 

nococcus of the kidney. If 

this latter condition exists, 

then the aspirated fluid shows 

absence of the usual urinary 

constituents and the presence 

of the "hooklets" which are 

peculiar to echinococcus. 
Large ovarian tumors are 

more likely to be mistaken for 

hydronephrosis, although they 

are quite rare. These cysts of 

the ovary are spherical, 

smooth, and fluctuating, but 

they arise in the false pelvis. 

They occupy the region of the 

umbilicus and the hypogas- 

trium, while the lateral por- 
tions of the back are free 

from tumor. 

Distended bladder is easily differentiated, for it occupies a 

more central and low position in the pelvis, and catheterization 

results in the immediate re- 
duction of the tumor. 

Distended Bladder.— I f 
the abdominal walls are 
nearly normal, the tumor 
which results from distended 
bladder is easily mapped 
out. But at times there 
are conditions in the abdo- 
men or its walls which make 
such a procedure impossible 
or difficult, and then de- 
pendence must be placed 

upon other signs. If upon percussion we obtain a dull sound in 

the median line and between the symphysis pubis and the umbili 



Fig. 31. — Illustrating the lateral tympanitic 
areas and the dull central area caused by 
cystic or solid tumor of the abdomen. 



DULL 




Fig. 32.— Diagram explanatory of central 
dullness and lateral tympanicity in cystic or 
solid abdominal tumors. 



138 EXAMINATION OF THE ABDOMEN 

cus, and this dull sound extends symmetrically upon both sides 
of the median line, we are practically certain that there is a dis- 
tention of the bladder. There is no change of the sound with a 
change in the position of the child. The means of positive diag- 
nosis is the use of the catheter, for in distended bladder its use 
results in immediate reduction of the tumor. 

Chronic (Non-tuberculous) Peritonitis. — This is a very rare 
condition, and its diagnosis must be guardedly made, for the 
tuberculous form of chronic peritonitis is so common in comparison. 
It occurs in children who are entirely free from tuberculous taint, 
and there is always a definite history of some etiologic factor, as 
chilling of the abdomen, occurrence of some acute infectious 
disease, new-growths, or injury in the abdomen. 

Generally the first thing noticed is the enlargement of the 
abdomen, although this may be preceded by a group of very 
indefinite symptoms which have been so slight as to pass almost 
unnoticed until recalled by the taking of the history. The 
enlargement is gradual and the abdomen assumes within a few 
weeks a spherical form, the walls remaining somewhat lax. There 
may be some tension, but it is always slight, and upon pressure 
there is no tenderness or areas of hardening or thickening in the 
abdominal wall. 

While this enlargement is going on, the general condition of 
the child remains good, and for several months there may be no 
appreciable change in the general nutrition. If fever has been 
noted at all, it is only in the beginning of the disease and not 
thereafter. In the examination of the abdomen fluctuation is 
easily detected, and the dull sound upon percussion always oc- 
cupies the more dependent portions. 

The usual course of the condition is to reach a certain maximum 
point of development and then to remain quiescent for an indefi- 
nite period, with subsequent absorption giving permanent relief. 
Relapses may occur. 

Tuberculous Peritonitis. — This is usually a local expression 
of a general infection, but it may be primary, although this latter 
is rare. Some authors describe various forms of the disease, and 
these descriptions are based upon the location of the lesion and 
the changes which the parts undergo, but for practical purposes 



ENLARGEMENT OF THE ABDOMEN 1 39 

of diagnosis it is only necessary to recognize two forms of the 
disease — that which is plastic and that which is associated with 
ascites. 

The latter generally develops in a child who is in chronically 
poor physical condition; a child who is the subject of eczema, 
glandular enlargements, or has a family history of tuberculosis. 
Sometimes there is a preceding chronic diarrhea, or perhaps a 
condition of alternating diarrhea and constipation with indefinite 
abdominal pairi which has led to the suspicion of some intestinal 
digestive disorder. 

With the enlargement of the abdomen which takes place (there 
is considerable abdominal tension, with compression at the sides, 
so that the abdomen is not spherical in shape, but more oval) there 
is little fever, only a moderate amount of general weakness and 
malaise, and slight loss of weight. The enlargement of the abdo- 
men is the chief feature, as a rule. 

In childhood, any chronic ascites which is associated with even 
a very moderate fever should be considered as tuberculous until 
it can be proved otherwise. The diagnosis must not consider 
as very important the absence of cough or the general symptoms 
of tuberculosis, as they are usually observed in children, for 
tuberculous peritonitis may develop very insidiously. It cannot 
be too often repeated that the chest is not always the favorite 
site of tuberculosis in children, but that the peritoneum and 
meninges are very susceptible. 

Between the tuberculous and the non-tuberculous forms of 
peritonitis there is considerable difficulty in diagnosis at first. 
If there is no family history of tuberculosis and no signs of tuber- 
culosis in the lungs or any part of the body, it proves nothing 
against the existence of tuberculous peritonitis; if any of these 
are present, however, it is indicative of tuberculous infection of 
the peritoneum. 

If there is no abdominal tenderness anywhere and careful 
examination does not reveal any nodular tumors or points of 
thickening in the abdominal wall; if the enlargement is excessive 
and the child's general condition is not suffering to any marked 
extent, it is suggestive of the non-tuberculous type of peritonitis. 

As the disease progresses, then, the diagnosis becomes com- 



140 EXAMINATION OF THE ABDOMEN 

paratively easy; the abdomen is considerably increased in size, 
partly from gas and partly from fluid, and the result is that the 
abdominal walls are tense, the umbilicus prominent, the cutaneous 
veins distended over the abdomen, and soreness is complained of. 

There are one or more areas in the abdomen in which induration 
is detected with well-defined borders, and pressure over these 
points is painful. The induration may be well enough developed 
to constitute a w T ell-defined tumor which is nodular. 

The child at this later stage of the disease shows unmistakable 
signs of the seriousness of the disease, and there is generally a 
well-marked wasting, which is most noticeable in the chest, neck, 
and limbs. The wasting and the associated enlarged abdomen 
give a contrast which is most noticeable. 

The temperature is about normal in the morning, but elevated 
in the evenings, although for no apparent reason it may be normal 
persistently for three or four days at a time during the course of 
the disease, and if this possibility is not remembered, there is a 
chance for erroneous conclusions. 

The main points to recall in the diagnosis are that it is commoner 
in children than one is usually led to suppose, that the onset is 
insidious as a rule, that it is the chief cause of ascites in children 
with moderate fever, and that while the presence of tuberculous 
processes in other parts of the body is strongly confirmative, 
absence of such does not exclude the disease. 

Cirrhosis of the liver must be excluded as a cause. Ascites in 
cirrhosis of the liver usually comes as a late symptom, and indi- 
cates the seriousness of the case. Icterus is more or less prominent, 
and the history usually is corroborative. However, it may be 
necessary to examine some of the fluid to definitely determine the 
cause. 

The plastic form is here considered, not because it results in 
any considerable abdominal enlargement, but because of the 
importance of the recognition of tuberculous peritonitis of any 
form. In this type the abdomen is generally flat or may be slightly 
distended, but distention is mostly due to gas and not to fluid. 
If palpation is thoroughly performed, it is usually possible to 
detect several nodules or enlarged glands, matted omentum, or 



ENLARGEMENT OF THE ABDOMEN 141 

viscera, or, with the finger in the rectum, tuberculous masses and 
bands may be felt in the lower bowel. 

This form is recognized by the presence of the above-mentioned 
signs, associated with chronicity and very noticeable wasting and 
fever. Corroborative evidence would naturally be offered if 
one were able to demonstrate a tuberculous infection in some 
other part of the body. 

Malignant Tumors of the Kidney. — The great majority of 
tumors of the kidneys in children are sarcomata, and of all of the 
malignant abdominal tumors, sarcoma of the kidney is the most 
common. Generally, the tumors are atypical, so that they are 
often classed as teratomata, in some cases being of a cystic or 




Fi S- 33-— Sarcoma of both kidneys in a male child, two years old. The tumors are outlined 
to show their extent (Napier). 

adenomatous type, but still malignant, or they may combine 
some of the features of sarcoma with some of carcinoma. But 
whatever their nature, they grow rapidly and sometimes are so 
soft that they may be mistaken for chronic abscess. 

The tumor is usually the first thing noticed, and the commonest 
situation is in the loin at first, whence it seems to grow rapidly 
forward toward the median line. The surface of the tumor nun- 
be quite smooth, irregular or lobulated, and the growth is so 
rapid that within three or four months from its discovery the 
tumor may almost completely fill the abdomen. When the tumor 
is small, its connection with the kidney can generally be easily 
mapped out. 



142 



EXAMINATION OF THE ABDOMEN 



Hematuria is a frequent symptom, and in a small number of 
cases has been observed as the first symptom, but this is unusual, 
for it is generally of late occurrence. The amount of blood may 
be large, but in most instances it is small, and so small that it is 
not appreciable to the unaided eye. 

Pain is a rare and always a late symptom. When the tumor is 

of considerable size, the general 
symptoms (cachexia and steady 
wasting) first show themselves. 
Pressure symptoms depend upon 
the size and situation of the 
tumor. 

There is usually no difficulty 
in the diagnosis, the age of the 
child (under five years), the at- 
tachment of the tumor (to the 
kidney), the rapid growth (filling 
the abdomen in three or four 
months) , and the character of the 
tumor usually being sufficiently 
pronounced to distinguish it. 
Still, malignant tumor may be 
mistaken for hydronephrosis, and 
exploratory puncture may be 
necessary, which in the latter 
disease would yield fluid with 
urinary constituents, and in ma- 
lignant tumor would prove nega- 
tive in nearly every instance. 
The needle is best inserted half- 
way between the last rib and the 
crest of the ilium, three inches 
from the spine. If the hydronephrosis depends upon some 
traumatism, then there is the history of an injury associated with 
hematuria, and later the development of a tumor which on punc- 
ture yields a clear urinous fluid. 

Ovarian cysts must be differentiated by a bimanual examination 
through the rectum and abdomen, and this is best done under 




Fig. 34.— Sarcoma of both kidneys in 
a male child two years of age. The 
tumors are here outlined to show their 
extent (Napier). 



ENLARGEMENT OF THE ABDOMEN 



H3 



anesthesia. If the ovarian tumor be large, then it is spherical, 
smooth, and fluctuating, and occupies the umbilical region and 
the hypogastrium, the lateral parts of the back remaining free. 
Retroperitoneal sarcoma and tumors of the abdominal wall must 
also be distinguished, and these are considered later (see the 
following). 

Retroperitoneal Sarcoma. — This may be an irregular tumor 
of large dimensions, and is felt in the lower portion of the abdomen, 
or sometimes in its lateral portions between the crest of the 








Fig- 35.— Sarcomatous tumors of the kidneys, removed from a child two years of age. 



ilium and the lower ribs, and in this latter situation may simulate 
a sarcoma of the kidney. The differentiation is made by the 
more central position of retroperitoneal sarcoma and the normal 
condition of the urine. However, an exploratory incision is 
sometimes necessary to distinguish it. 

Tumors of the Abdominal Wall. — These may be due to the 
formation of inflammatory exudates. They are easily dist inguished 
on account of the strict localization. Sometimes (and par 
ticularly in young girls who are neurotic) there is spasm of the 



i 4 4 



EXAMINATION OF THE ABDOMEN 



recti muscles, which may simulate tumors of the abdominal wall, 
but anesthesia soon dispels these. 



ENLARGEMENT OF THE LIVER 
At the time of birth the liver represents about one-eighteenth 
of the whole body-weight. The normal position at that period 
is so that the superior border of the right lobe extends in the 
midscapular line to the seventh rib; in the midaxillary line 
to the sixth rib, and in the midclavicular to the fifth, rib. The 

inferior border extends 
in the median line not 
quite to the umbili- 
cus. The lateral mar- 
gin of the left lobe lies 
about one inch to the 
left of the median 
line. The upper mar- 
gin of the left lobe is 
difficult to find on ac- 
count of its being so 
close to the area of 
cardiac dullness. 

The increase in the 
weight of the liver does 
not keep pace with the 
increase of the body- 
weight. 

Quite soon after birth 
the area of liver dull- 
ness shows a decided 
diminution, and this is 
because of the elonga- 
tion of the abdominal portion of the spine and the rapid growth 
of the infant's stomach. 

Later on in childhood the descent of the diaphragm causes the 
liver to descend, so that at this period it is one or one and one-half 
inches lower (in its upper border) than in infancy. 




Fig. 36. — Outlines of the liver. The solid line indi- 
cates the outline of the normal liver as the child ap- 
proaches puberty ; the perpendicular lines indicating the 
portion of the liver covered by the lung. The dotted 
line shows the position and extent of liver dullness at 
birth. As the infant develops, the liver rapidly decreases 
in extent and the position is much changed. 



ENLARGEMENT OF THE LIVER 145 

The lower border progressively ascends until the time of puberty, 
at which period it generally corresponds with the lower border 
of the ribs. 

Acute Enlargement of the Liver. — In early life it is difficult 
to definitely palpate the liver, for it is soft and yielding, but later 
on, when the organ has more solidity, the procedure becomes 
much simplified. 

If the liver is acutely enlarged and the surface remains smooth 
and with a moderate degree of hardness, then such a condition 
suggests bile stasis. The most frequent cause of such stasis is 
catarrh, and next in frequency there are the congestions of the 
organ which are so often associated with infectious disease of any 
kind. In both instances, with the subsidence of the cause, the 
enlargement also disappears. 




Fig- 37.— Palpating the liver. 

In diagnosing acute enlargement there must be an exclusion 
made of those conditions which simulate it, as pleural effusions 
(in which the pulmonary affection and the general conditions 
which cause it must be all considered), subdiaphragmatic abscess, 
and spasm of the recti muscles. 

Congestion of the Liver. — This can hardly be classed as a 
disease, and yet its importance is in its early recognition, as it is 
the condition which precedes every structural change in the liver. 
Hepatic congestion is either active or passive, and the most 
common causes of the active form are overfeeding, and particu- 
larly with fatty foods, the acute infections, cold, and shock. Of 
the passive form, the common causes are pulmonary obstruction. 
10 



146 EXAMINATION OF THE ABDOMEN 

and especially from pneumonia, atelectasis, pleurisy or emphy- 
sema, cardiac weakness, malaria, and chronic gastro-intestinal 
disorders. 

There is always more or less hepatic enlargement, but it is easy 
to be deceived and to attribute this to the developmental period. 
Outside of the moderate increase in size of the organ, there are 
no symptoms which are constant, so that its recognition is often 
overlooked. In the active form there may be some tenderness 
over the organ. The passive form becomes chronic in nearly 
every instance, for the conditions causing it are usually of a 
chronic or persistent nature. 

Suppurative Hepatitis. — This may be due to traumatism, 
pelvic peritonitis, umbilical phlebitis, tuberculosis, any acute 
infectious disease, or empyema. In infancy the symptoms are 
far from being characteristic, and there is the added difficulty of 
palpation which is not satisfactory. A loop of the intestine 
frequently gets in between the palpating fingers and the lower 
border of the liver, and this gives an apparent difference in the 
density of the liver, and abscess is at once suspected. Pain, which 
is ordinarily a valuable sign, is sometimes obtained when no 
abscess is present, for at times the pressure of the liver upward 
causes pain because of the existence of a pleurisy (which has not 
been suspected). The only reliable means of diagnosis is by ex- 
ploratory aspiration, which may demonstrate the presence of pus. 

Acute Infectious Liver. — During the course of the acute 
infectious diseases there occurs with considerable regularity an 
active congestion of the liver with interference with its function, 
and the subsidence of the causative disease usually means a disap- 
pearance of the symptoms of hepatic congestion and also of the 
moderate enlargement. But occasionally such is not the for- 
tunate course, and instead of a disappearance of the symptoms, 
we encounter those of an acute infection, as chills, anorexia, 
remittent fever, vomiting, etc. 

The liver becomes more enlarged, tenderness is more or less 
marked, and there are other symptoms of hepatic abscess. This 
condition may persist for weeks with more or less prominent symp- 
toms of sepsis. The diagnosis is made from the history and 
confirmed by aspiration. 



ENLARGEMENT OF THE LIVER 147 

Chronic Enlargement of the Liver. — If the liver is chronically 
enlarged and with a smooth surface, it may be due to cardiac 
disease, chronic pleurisy, empyema, or to any disease or condition 
which interferes with the free return of blood to the heart. 

Cirrhosis of the Liver. — There are two distinct stages to this 
disease, the first stage being one of enlargement of the organ, the 
second one of contraction. The disease is more common among 
children than is generally supposed, being due in many instances 
to chronic passive congestion from renal or cardiac disease, 
stenosis of the bile-ducts, syphilis, malaria, tuberculosis, the acute 
infections, and rachitis. The effect of chronic poisoning by tea, 
coffee, etc., is, I believe, problematic. 

The local symptoms are first present, and then, by their inter- 
ference with the general nutrition of the child, general symptoms 
are added. The local symptoms depend upon the amount of 
obstruction to the portal circulation. At first the symptoms are 
those of hepatic enlargement associated with gastritis. Later, 
the symptoms are more severe and are due to obstruction of the 
portal capillaries. These symptoms are ascites; the abdomen 
becomes distended and there is a sense of weight and fullness. 
The distention may be very marked. The spleen is enlarged to 
twice its normal size, although the ascites may interfere with 
the examination of the spleen. Constipation is the rule, although 
a violent diarrhea may occur at any time. Taken all together, 
the symptoms do not differ from those which are present in adult 
life ; the only difference is that all of the symptoms are naturally 
influenced by the immaturity of the child. 

The methods of diagnosis are the same as in the adult. The 
occurrence of jaundice is a most important symptom, for it is 
always present in children who are suffering with cirrhosis of the 
liver. It may not be prominent, but may be moderatelv developed, 
with definite periods of exacerbation. If the case is seen late 
when ascites is present, the history is of immense value, as is 
also the demonstration of a small liver associated with a large 
spleen. 

Amyloid Disease. — The precise defect in metabolism which 
produces the deposit of amyloid substance in the middle coat of the 
arterioles, resulting in a waxy liver, lardaceous kidney, sago 



148 



EXAMINATION OF THE ABDOMEN 



spleen, etc., is not at all understood. It is fortunate, however, 
that some of the etiologic factors are understood, and these are 
the chronic tuberculous and syphilitic processes which affect 
the bones. 

The presence of the disease as affecting the liver is evidenced 
by enlargement of the organ (the liver sometimes extending down 
to the umbilicus), while at the same time it is hard, with rounded 

edges, a smooth surface, and no tender- 
ness upon pressure. There are also no 
symptoms of an arrested hepatic 
function. It does not occur indepen- 
dently, but there is the associated 
ulcerous borie affection. As the dis- 
ease never affects the liver alone, 
there is also splenic enlargement, and, 
the kidney being involved also, we 
find albuminuria present. 

Fatty Liver. — This may be present 
in children who are overfed with fatty 
or sweet sugary foods, as well as in 
those who are the victims of wasting 
disease. The disease is evidenced by 
hepatic enlargement, with the surface 
of the organ entirely smooth, and the 
enlargement being moderate and the 
liver not very hard. There is no pain 
or tenderness, and icterus and ascites 
are absent. It is particularly liable 
to affect children who are the sub- 
jects of tuberculosis or rachitis. 
Leukemic Liver. — This is similar to the liver seen in amyloid 
disease, but there is an absence of the etiologic factors of amyloid 
disease and the presence of unmistakable symptoms of leukemia 
(see Leukemia). 

Echinococcus of the Liver. — This differs from all other forms 
of enlargement by its very slow and steady course (taking years 
to develop) and by the general good health of the affected child. 
There is an absence of ascites and also of icterus. 




Fig. 38. — Amyloid liver (out- 
lined) in a child who was suffering 
from Pott's disease. Child is fast- 
ened upon a Bradford frame 
(Napier). 



ENLARGEMENT OF THE SPLEEN 149 

When a cyst is palpable, there is detected upon the free border 
of the liver a half spherical and smooth convexity. This gives 
fluctuation. The fluid which may be drawn from this cyst 
differs from all other exudates or transudates in being rich in 
sodium chlorid and showing an entire absence of albumin which is 
coagulable by boiling. If a microscopic examination is made, 
the hooklets of echinococcus may be revealed. 

Sometimes it is possible to demonstrate the hydatid thrill, 
which is a sensation which is conveyed to the palpating finger as 
of a cushion with a spring in it. When percussion and ausculta- 
tion are performed simultaneously, there is a distinct, deep, 
sonorous tone, and this is known as the hydatid resonance. 

Syphilis of the Liver. — In a child of considerable age there 
may be a marked increase in the size of the organ, and on account 
of the formation of cicatrices and gummatous nodes, the organ 
may be lobular. The diagnosis is made by exclusion and by the 
history of previous syphilitic affection, and is confirmed by treat- 
ment. 

Tumors of the Liver. — These are so rare that they are men- 
tioned simply for completeness. Such growths are rarely, if 
ever, primary, so that the diagnosis is simplified by the history 
of tumors in other parts. 



ENLARGEMENT OF THE SPLEEN 
At the time of birth the spleen weighs about one-fourth of an 
ounce. It is very seldom that it can be made out by palpation, 
as it is situated so close to the posterior and descending wall of 
the diaphragm, opposite the ninth, tenth, and eleventh ribs, and 
covered anteriorly by the stomach. If it can be palpated at 
birth, then one of two conditions is present — it is enlarged or 
displaced. The long axis of the spleen is about parallel with the 
ribs. 

Percussion of the spleen gives a dull sound which is st rough' in 
contrast with pulmonary resonance above and the tympanitic (in- 
testinal) note below. But percussion is not always satisfactory, 
for the results must be the same on successive days to be of value 
in diagnosis, and while this is being demonstrated, much time is 



150 EXAMINATION OF THE ABDOMEN 

necessarily lost. Palpation is much more satisfactory, and this 
must be performed with the child on the back and with the legs 
flexed. All manipulations must be very gently but firmly per- 
formed, the pressure being at first light and then gradually in- 
creased as required. A moderate degree of enlargement may be 
said to exist when the lower border of the spleen can be palpated 
an inch below the free borders of the ribs. 

Splenic tumor is recognized in the left hypochondriac region, 
by being freely movable laterally and at the lower border, while 
above it is attached. The inner border is palpated as a thin and 
rather sharp edge with a deep notch in its middle portion. An 
enlarged spleen generally retains it original shape, as the increase 




Fig- 39- — Method of palpating the spleen. 

is, as a rule, in all diameters. Enlargement of the spleen occurs 
as an acute or chronic condition. 

Acute Splenic Enlargement. — This occurs in certain of the 
acute infectious diseases, as typhoid fever, malaria, diphtheria, 
epidemic cerebrospinal meningitis, blood-poisoning, and variola. 
The splenic enlargement is constant in two diseases, typhoid and 
malaria, and this may prove of considerable value in differential 
diagnosis, for it is not uncommon to find that in their early 
symptoms some of the gastric disturbances and meningitis mark- 
edly simulate typhoid fever, and the absence of splenic enlarge- 
ment would at once arouse doubt as to the existence of the latter 
disease. While a diagnosis of typhoid fever cannot well be made 
without the demonstration of some splenic enlargement, it must 



ENLARGEMENT OF THE SPLEEN 



151 



also be remembered that such an enlargement occurs in other 
fevers. 

To be positive that an acute enlargement actually exists, we 
must be certain that such enlargement did not previously persist. 
It is not infrequent to have chronic enlargement present, and then, 
when some febrile condition occurs and the spleen is examined, 
the first note of its enlarged condition is made. One feature of 
acute enlargement is that there is usually slight pain present. 
There are some congenital conditions which are accompanied by 
acute splenic enlarge- 
ments, and these are: 
Occlusion of the bile- 
ducts, umbilical phlebi- 
tis, hepatitis, infectious 
hemoglobinuria. Splenic 
abscess and acute spleni- 
tis from emboli are rare 
causes of acute enlarge- 
ment. 

Chronic Enlarge- 
ment. — In chronic en- 
largement the spleen is 
not only enlarged, but it 
is noticeably harder than 
usual. The degree of 
enlargement is generally 
such that the spleen ex- 
tends for over two inches 
below the border of the 

ribs. In most cases there is an absence of any acute febrile con- 
dition. 

One must not be misled by mistaking chronic enlargement for 
acute enlargement when some acute febrile condition is existent. 
In infancy chronic enlargement is most common in rachitis and 
hereditary syphilis. In rachitis it is most frequent during the 
first year of life and is usually present only in the severest types 
of the disease, and this fact makes the chances of mistaking the 




Fig. 40.— Outlines of spleen. Normal splenic dull- 
ness is observed between the ninth and eleventh ribs 
and at times slightly below the eleventh rib. The 
perpendicular lines indicate the portion of the spleen 
covered by the lung. 



152 EXAMINATION OF THE ABDOMEN 

cause of the enlargement almost nil, for the other symptoms of 
rachitis are so fully developed. 

Occurring in the course of hereditary syphilis, the other symp- 
toms may remain obscure for a considerable length of time, and 
the splenic enlargement and the indefinite general symptoms 
might readily lead one to suspect leukemia or amyloid spleen, and 
this is particularly true if the anemia which is sometimes very 
marked in syphilis is a pronounced feature. 

If the white blood-corpuscles are not increased, then leukemia 
is excluded as a cause, and when the differentiation is to be made 
between amyloid disease and hereditary syphilis, the histories 
are most valuable, and are really the determining factor. In 
amyloid disease there is suppuration going on somewhere in the 
body, and the liver is enlarged as well as the spleen. 

After the period of infancy is past, chronic splenic enlargement 
is in nearly every instance due to chronic malarial poisoning. In 
regard to the recognition of chronic malarial poisoning, the 
history of a malarial cachexia and the blood-condition are usually 
sufficient to distinguish it. 

In simple anemia with a moderate leukocytosis, during the 
period of infancy, splenic enlargement may be pronounced, but 
the association is generally with some gastro-intestinal disease, 
syphilis, or rachitis, and there is sufficient reason to believe that 
while the cause remains obscure, it does so only because of our 
inability to recognize it with present methods. Probably the 
splenic enlargement is always secondary to some infection which 
has not been recognized. In leukemia and in Hodgkin's disease 
there is splenic enlargement of a chronic type, but there is con- 
siderable enlargement of the liver also. 

New-growths of the spleen causing its chronic enlargement are 
rare, but they do occasionally occur, and when they do, they are 
generally varieties of sarcoma. They are rarely, if ever, primary, 
and are recognized by the occurrence of malignant disease else- 
where in the body, and by the associated symptoms of malignant 
growths. 



DIARRHEA 

Diarrhea is a sign of some disorder of the intestine and may 
exist as an acute or a chronic disorder. While it is a symptom, it is 
of itself the cause of other symptoms. Diarrhea may be said to 
exist when there is an increased frequency of the acts of defe- 
cation or when there is an abnormal fluidity of the stool. In- 
creased frequency is generally due to increased peristalsis, but 
not all increased peristalsis results in diarrhea. 

In nurslings the bowels should be moved twice or three times 
during the twenty-four hours, and the stool should be of jelly- 
like consistency and without an excessive amount of fluid present 
(a normal amount of fluid would be such as would wet the diaper 
to a similar extent as would about a half-teaspoonful of water). 
The color should be yellow or orange, and the odor never ought 
to be more than faint. There is normally a varying quantity of 
mucus, which is closely admixed with the stool and never separ- 
ated from it or gathered into distinct lumps. Mucus which is 
visible to the unaided eye is always indicative of an excessive 
production. 

In the older child, after the period of weaning there is a much 
closer approximation to the adult both in regard to the frequency 
of the movements (which should be one or two in the twentv-four 
hours) and the consistency of the stool (which should be well 
formed). The color is gradually changed as the child ages, so 
that from the yellow stool of the nursling it becomes a dark 
brown as milk as an article of diet is substituted bv other things. 
The odor also changes, becoming somewhat stronger, but never 
offensive. 

The etiologic factors of diarrhea are chiefly four in childhood 
and infancy: Age — one year and under, during which time the in- 
fant is very susceptible. Season — summer, and espeeiallv during 
a protracted heated term. Poor hygienic surroundings. Im- 
proper feeding, whether of quantity, quality, or composition, 

i53 



1 54 DIARRHEA 

Of the cases which have a fatal issue, the four chief associated 
factors are tuberculosis, rachitis, marasmus, and hereditary 
syphilis. 

In a determination of the number of movements which have 
occurred it is advisable to get into the habit of asking at what 
time the movements occurred. Two things are conserved by 
this : First, it impresses the mother with the fact that the condition 
of the bowels is not a matter to be slighted, and it prevents the 
possibility of exaggeration, which is common enough. Many 
times I have tested intelligent mothers and received the statement 
that the baby's bowels moved surely a dozen times, and then 
when definite information was sought in regard to actual time, 
observed that the dozen shrank rapidly to three or four. Sec- 
ondly, and of more importance still, it furnished a clue to diag- 
nosis in those occasional instances where malaria exhibits most 
of its periodicity upon the condition of the bowel. Several 
evacuations occurring within a short time and periodically may 
be the first hint of the real cause. Another thing that must be 
considered is the fact of possible drug ingestion by the child or 
the nurse, for these frequently are the cause of increased move- 
ments. 

In deciding about the color of the movement, inspection must 
follow almost immediately after an evacuation. Most stools 
turn green very shortly after their passage and also become drier 
upon exposure to air. Following the administration of calomel 
or of bicarbonate of soda, the color of the stool may be quite 
green even at the time of its passage. 

The symptoms which are associated with diarrhea depend 
largely upon the cause and somewhat upon the frequency of the 
movements. They are chiefly pain, tenesmus, and flatulence. 

The pain is especially dependent upon the cause. If the 
irritating material is some product of digestion, pain is referred 
to all portions of the abdomen and is usually quite severe, being 
particularly marked immediately before a movement. If due 
to inflammation, the pain is more constant and localized. 

Tenesmus depends most upon frequency, so that it is almost 
uniformly observed in diarrheas from any cause in which the 



CAUSES OF ACUTE DIARRHEAS 1 55 

evacuations are very frequent. It is noticeable with greatest 
severity immediately after the bowel has been evacuated. 

Flatulence is common in most of the diarrheas of infancy and 
itself is the cause of much distress. Usually it is general over 
the abdomen, but in enterocolitis is more localized over the 
course of the colon. 

General symptoms are elevation of temperature and more or 
less weakness, according to the cause and the severity of the 
diarrhea. Prostration is an accompaniment of all forms, while 
collapse is observed most frequently in cholera infantum. 



CAUSES OF ACUTE DIARRHEAS 

There are in children disorders which are called functional, 
and these, when they affect the condition of the intestines, are apt 
to do so not alone, but with an associated involvement of the 
whole gastro-intestinal tract. We do not fully understand the 
nature of a so-called functional disturbance, and so many times 
the beginning of disease is masked under this flexible term, until 
such time as its development is so marked that a definite clinical 
entity can be recognized. 

The necessity for the use of the term in the gastro-intestinal 
disorders of childhood is unfortunate, for the slightest disturbance 
in this class of cases should receive prompt attention. This is 
especially true of diarrheal conditions, which, until their nature 
is thoroughly understood, should be treated as the possible begin- 
ning of a fatal disease; this applies with most force during the 
first year of life. 

When the food enters the stomach, it carries with it innumerable 
rjacteria. Some of these are at once destroyed, others are reduced 
in virulence, and still others pass on unchanged into the intestine. 
If the number of the latter be large, they are capable of producing 
organic acids in the small intestine by a decomposition of the 
carbohydrates or a splitting of the fats. The food is passed with 
considerable rapidity (a few hours at most) through the duodenum 
and the ileum, so that here there is little time for bacterial mul- 
tiplication. In the large intestine the passage is slower and the 
amount of material which is absorbed leaves little to decompose. 



156 



DIARRHEA 



But the greatest protective factor seems to be the inhibitory 
control which the normal intestinal bacteria exert upon other 
bacteria. Let this action become disturbed, as it seems to be 
in the so-called functional disorders, and one can easily see that 
the infant becomes an easy victim to intestinal disease. 

The development of the normal intestinal flora occurs as early 
as the fourth day of life. Most of the intestinal disorders can be 
reasonably traced to an abnormal bacterial action in the intestine. 

The normal bacteria of the bowel may either increase in num- 
ber or in virulence, or other bacteria may give rise to pathologic 
conditions. Bearing this in mind, we must recognize at once 
that, during infancy at least, there are many factors which may 
influence the onset of diarrhea. 



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Nervous Diarrhea. — This may have its cause outside of the 
intestine. A shock, such as the sudden chilling of the body, may 
be sufficient to produce it. In others it is brought about only 
by some definite condition which produces nervousness. Usually 
in diarrheas of this type it is not difficult to discover neurasthenic 
or hysterical stigmata. The watery character of the stool is 
probably due to a hypersecretion from the intestinal mucosa, 
under the influence of nervousness. This diarrhea is character- 
ized by several watery movements (five or less) occurring suddenly 
under the influence of some excitement or fatigue, and as suddenly 
stopping within a few hours when the nervous condition has had 
time to subside. 



CAUSES OF ACUTE DIARRHEAS 1 57 

Eliminative Diarrhea. — Between the diarrheas due to nervous 
influences and those which are due to intestinal disease there is 
a type which is best termed eliminative diarrhea, as its exact 
mode of production is not fully understood. It accompanies 
many of the general diseases and i3 most typically observed in 
uremia and in some of the acute infectious diseases, particularly 
rubeola. That toxins produced by the general disease cause the 
condition is the most reasonable deduction. The diagnosis must 
take into consideration the associated general disease (particularly 
its severity) , and there must be an exclusion of all other possible 
causes. 

Fat Diarrhea. — This is a form of dyspepsia. There is an 
increase in the amount of fat in the stools of all children who are 
the subjects of dyspepsia, irrespective of the underlying cause, 
but in this disease the increase is very marked. In all other 
particulars the stool is similar to that of the dyspeptic. Micro- 
scopic examination of the stool reveals the presence of large 
amounts of fat ; the whole field is crowded with large fat-globules. 

Acute Intestinal Indigestion. — Diarrhea is a constant feature 
of this disease. According to the development, there are asso- 
ciated with the disease gastric symptoms: with a sudden onset 
they are present ; with gradual development they are absent. I 
shall first consider the disease as it affects infants, and later will 
make reference to the dissimilar symptoms in the older child. 

The local symptoms are pain, tympanites, and finally diarrhea. 

Pain is evidenced by the sharp, piercing cry, marked restless- 
ness, and drawing up or throwing about of the legs; or, in other 
words, there is a sharp attack of colic. There is an elevation of 
the temperature to 102 to 105 F., but within twelve to twenty- 
four hours this has returned nearly to the normal point. Asso- 
ciated with the fever there is much prostration, which may be 
severe enough to threaten the life of the infant. The pulse is 
rapid and the prostration is shown by the drawn features and 
general muscular weakness. 

Tympanites may not be marked at the onset, the rule being a 
gradual development of this symptom. 

Within a few hours of the onset the diarrhea sets in. and the 
stools are increased to from four to twelve in the twenty-four 



158 DIARRHEA 

hours. The first stools are fecal, but rapidly become less so r 
assuming a yellow, then a greenish-yellow, and finally a grass-green 
color. The consistency is soon lost, so that within a few hours 
the stools are fluid. The odor becomes sour or may be foul. 
Unless the disease has continued for several days there is no 
mucus present in the stool. Undigested food is always present, 
however, and this is seen as lumps of casein or of fat. 

The course of the disease depends upon several factors, chief of 
which are the previous condition, the nature of the exciting 
cause, and the time at which treatment was instituted as well as 
its nature. With an infant in previous good condition, prompt 
removal of the cause and proper treatment early applied, the 
disease lasts about forty-eight hours. Otherwise the disease may 
become the factor which allows the development of a pathologic 
process of the intestinal with serious organic changes. 

In older children, several hours before the occurrence of diarrhea, 
pain is complained of about the navel. The temperature is not 
elevated markedly, but usually rises to between 10 1° and 102 F. 
Like the temperature, the prostration is by no means marked, 
nor are the consequences of the disease such as is frequently 
observed after an attack or a succession of attacks in infants. 

The diagnosis may sometimes be made from the early symptoms, 
when there is a clear history of a sufficient cause and of previous 
attacks. But it must not be forgotten that many of the acute 
infectious diseases begin with very similar symptoms, so that 
much caution must be exercised until the occurrence of the diar- 
rhea. From other diarrheal diseases it is distinguished by the 
shorter course, the less marked nervous symptoms, and the 
character of the stool. 

Acute Gastro-enteric Infection. — There are two quite dis- 
tinct developments of this disease — the mild, with a gradual 
onset, and the severe, with a rapid occurrence. These will be 
described separately. 

The mild form with a gradual onset has symptoms which in the 
beginning are so slight that the case is usually considered one of 
"teething" by the parents. There is at first little or no fever 
and but slight, if any, gastric disturbance. In fact, it is not 
unusual to find that during the first three or four days the diarrhea 



CAUSES OF ACUTE DIARRHEAS 1 59 

is the only symptom, possibly accompanied with some peevish- 
ness. There is one characteristic of the movements — they 
increase in frequency. The stools are thin, and may be green, 
brown, or yellow. 

The tongue is coated, the appetite is but little changed, but in 
infants who are not in good condition generally, thrush may 
develop. The general condition of the infant is one of flabbiness 
and evident weakness. Toward the end of the first week the 
odor of the stool becomes offensive and mucus is present as well 
as undigested food. 

The infant is now in a condition during which the slightest 
error in diet or lack of care will result in a relapse which is more 
often of the severe type to be shortly described. However, 
with proper care, diet, and treatment, there is a gradual improve- 
ment so that the child is well again in about two weeks. 

In the cases with a sudden onset there may be no warning, or 
for some days previously there may have been evidences of slight 
intestinal derangement. The infant is restless and is in evident 
discomfort, crying much of the time. The temperature is rapidly 
raised to 102 to 106 F., and all indications point to a sudden 
and severe illness. The prostration is sometimes marked; the 
infant lies in a dull stupor with sunken eyes and a general relaxa- 
tion, or may be delirious. Thirst is excessive, but whenever 
fluid is given, it is almost immediately vomited. The vomiting is 
an occurrence which comes on about four or five hours after the 
first symptoms of the onset, and is first of the stomach contents, 
which have become sour; then, when continued, it consists of 
mucus, bile, and serum. 

Except those cases in which slight intestinal disturbance is 
present for a few days before the onset, diarrhea does not show 
itself until several hours after the sudden onset. The first stools 
are fecal, but it is not long before they are simply bursts of flatus 
which bring with them a thin yellowish or greenish-yellow material 
which has an offensive odor. It is not usual for the color to be 
brown, yet this is sometimes the case. The color is somewhat 
typical, but the really characteristic features are the amount of 
flatus and the odor. The movements may occur hourly, and 
preceding them there is more or less crampy pain. 



l6o DIARRHEA 

After the first day, although there may be little improvement 
in the condition of the bowels, there is generally an improvement 
in the general condition of the infant. Under the most advan- 
tageous conditions two or three days may witness the establish- 
ment of convalescence, but conditions are not usually so excellent, 
and there is a development of ileocolitis (see page 1 6 1 ) . In other 
cases, inztead of the expected improvement, there is a steady 
decline, with a rapid termination in death. 

In older children the clinical picture is much the same as in 
infants, but there are less vomiting, prostration, and temperature, 
with more pain and more rapid improvement. 

The diagnosis is made mainly from the character of the stools, 
which is substantiated by the mode of onset and the associated 
symptoms. Until the stools become somewhat typical, the onset 
may suggest any of the acute infectious diseases, pneumonia, and 
influenza. For the exclusion of the first, one must wait until the 
time for the appearance of the eruption; in regard to the second, 
the increased respirations and physical signs aid in the detection 
of pneumonia, and from influenza one has to recall the peculiarities 
of the disease in different epidemics, and these usually make the 
distinction clear. 

Acute indigestion cannot always be excluded or recognized, 
but, as a rule, such attacks are not accompanied by so great a 
disturbance of the nervous system, by such offensive and frequent 
stools, nor by the flatus which is so evident in acute gastro-enteric 
infection. 

Naturally, the influence of heated terms in the production of 
the disease will offer some help in the differentiation. When the 
condition of the bowels improves and the other associated symp- 
toms do not do so proportionately, it should at once arouse a 
suspicion of some other disease. 

Cholera Infantum. — This is fortunately a rare disease, with 
an intimate clinical association with gastro-enteric infection, so 
that severe cases of the latter are not always distinguishable 
from cases of cholera infantum. 

Usually the onset is abrupt, with persistent vomiting and high 
temperature, and this following some preceding intestinal disorder. 
Primary cases are comparatively rare. High and gradually 



CAUSES OF ACUTE DIARRHEAS l6l 

rising temperature with marked early prostration usually marks 
the onset of the disease, and within a very few hours there are 
the added symptoms of vomiting and diarrhea. Vomiting 
usually precedes diarrhea by three or four hours or both may 
develop together. The first vomiting is of the stomach content, 
then serum, mucus, and bile. Usually within twelve hours the 
diarrhea is well established, twenty to forty or more movements oc- 
curring in one day, and being so large and so fluid that they drain 
the body of its fluids. After the first few stools the movements 
seem to consist of serum, which is readily absorbed by the diaper 
and has a putrefactive odor. 

The draining of fluids from the body and the high temperature 
soon cause the child to become pallid, pinched, and flabby, the 
sunken eyes exhibiting a rapidly gathering film, the fontanelle 
depressed, cold, corpse-like extremities, and general marked 
prostration, while the temperature may be 105 to 107 F. The 
abdomen is flattened or sunken (usually the latter). The cry 
is reduced sometimes so that it is simply a moan or whine. Within 
twenty-four hours of the onset the infant may be close to death, 
which may be delayed for another day or two, for cases rarely 
recover. Occasionally instances are observed where death ensues 
within five or six hours. The loss of weight is more noticeable 
in cholera infantum in a corresponding period than in any other 
condition. Thirst is never satisfied; the child constantly desires 
liquids. 

The clinical picture is so typical that there is no chance for 
any error in diagnosis. 

Acute Ileocolitis. — Inflammations of the colon, ileum, and 
large intestine have unsatisfactory classifications, which is largely 
due to our ignorance of the true conditions present. But without 
entering into this fully, it is enough for our purposes to make the 
statement here that colitis and ileocolitis are not sufficiently 
marked to claim separate consideration, except as they do in this 
section, in which the distinction is lost under the heading ileoco- 
litis. This disease usually follows some infective enteritis, espe- 
cially acute gastro-enteric infection. 

The general course of the disease exhibits this peculiarity — 
that the severity of the symptoms is not fully explained by the 



1 62 DIARRHEA 

lesions, so that the influence of toxins must occupy a large place. 
Usually the development is secondary, but it may be primary, 
and in either event there is evidence of stomach disturbance 
associated with diarrhea and a rise in temperature. 

The onset is usually sudden, with the vomiting persisting for 
twenty-four hours (sometimes less), and the pain, frequency of 
the stools, and their character indicating little more than that the 
attack is probably due to an error in diet. Soon, however, the 
characteristic stools are present, and these are composed mostly 
of blood and mucus, their discharge being preceded by pain and 
accompanied and followed by tenesmus. The stools are frequent 
(usually every twenty to thirty minutes) and are also small 
(less than one-half ounce), but always discharged with much 
straining. The blood is usually streaked through the movement, 
and is rarely in any considerable quantity. 

The tongue is heavily coated, loss of strength and weight is 
quite apparent, and the child is visibly prostrated. At first the 
abdomen shows no marked changes, but later it generally becomes 
enlarged, tympanitic, and tender. The temperature for the first 
day is from 102 to 104 F., then ranges about ioo° to 101 F. 
for the rest of the time. Generally thirst is marked. 

Severe symptoms such as these persist for a week, after which 
there is a slow convalescence, the onset of which is first marked 
by the disappearance of blood from the stools. Following this 
there is a gradual subsidence of all the symptoms of the disease. 

In those cases which exhibit follicular ulceration there are some 
symptoms which are suggestive that the disease is of that type. 
In the first place, vomiting is not a marked feature, being only 
present for a very short time at the onset. The stools are less in 
number (from five to ten daily) and larger in amount, containing 
little, if any, blood, but large amounts of mucus (an ounce or more). 
The course is much more protracted, although all the initial 
symptoms are much improved after the first few hours. 

The membranous type is unusually severe and ordinarily fatal 
to life. Its chief development is between the ages of six months 
and two years. In this type the general symptoms are apt to be 
so extremely severe that they mask the intestinal ones to an 
extent. It can only be positively diagnosed during life if there 



CHRONIC DIARRHEAS 1 63 

are shreds of membrane discharged with the stool, and this is not 
the usual occurrence. Only small patches of membrane are 
discharged, and these are readily distinguished from mucus by 
washing. 

Ileocolitis must be differentiated from acute gastro-enteric 
infection, and this is aided by the consideration of the marked 
frequency of stools containing some blood and much mucus 
(or possibly membrane), by the character of the temperature and 
the vomiting. 

From intussusception the diagnosis is not difficult, for although 
there is a sudden onset with vomiting, pain, and marked prostra- 
tion, rise of temperature is absent in intussusception. The 
later symptoms of intussusception (obstinate constipation, 
tympanites, tumor, collapse, etc.) do not in any way simulate 
ileocolitis. 

The possibility of a mistake in regard to typhoid need only be 
thought of, the distinctive features being so marked. 



CHRONIC DIARRHEAS 

In the presence of any condition of chronic diarrhea the possi- 
bility of several diseases would at once be thought of: these are 
tuberculosis of the intestines and mesenteric glands, chronic 
ileocolitis, chronic intestinal indigestion, and malaria. I think 
that it will be well to describe these sufficiently in detail for their 
recognition, and then consider the differential diagnosis collec- 
tively. 

Tuberculosis of the Intest nes and Mesenteric Glands. — 
The almost invariable constancy with which these two conditions 
are associated makes it advisable to consider them together. 

The symptoms are anything but constant, and of all the incon- 
stant symptoms, diarrhea is the most constant, usually being 
exceedingly obstinate. The stools have nothing about them that 
is at all characteristic (they resemble those of chronic ileocolitis) 
except the presence of the tubercle bacilli. Hemorrhages may 
occur, but they are not very frequent occurrences. There may 
or may not be localized tenderness in the abdomen, which is 
usually soft. 



164 DIARRHEA 

Of course, when the case is a prolonged one, the symptoms of 
the intestinal ulceration are associated with those of peritonitis, 
and enlarged mesenteric glands may then be felt, if they are of 
considerable size. 

Chronic Ileocolitis. — After the symptoms of the acute attack 
have passed over, pain, tenderness, and temperature all may 
become so slight that they are scarcely noticeable. But the 
weight remains at a standstill and the general condition of the 
child continues to be bad. 

The little one is an easy prey to all infective processes, and 
stomatitis is common. In fact, all the chief symptoms arise 
from the fact of the existence of great physical depression, fer- 
mentation in the intestine, and alteration in the glandular struc- 
ture of that canal. Now, understanding that these three main 
conditions are present, it is needless to enumerate all the symp- 
toms which would result, for these vary with each child. 

There is a marked peculiarity of many of these cases, that they 
will not indicate a desire for food, but when it is offered to them 
they take it in almost unlimited quantities. And no matter how 
good the appetite, the child does not gain in weight and strength. 

The stools will average about five daily, being a little thinner 
than normal, and containing mucus in considerable amounts. The 
color of the stool may be gray, brown, or green, usually the latter. 
Undigested food is always present. The odor becomes offensive. 
The abdomen may be enlarged and puffed out. 

The child is peevish, restless, and cries almost continually day 
and night. Other than this, the symptoms depend upon the three 
conditions previously mentioned. Many of the children die 
during the first four months, but the disease may continue for a 
year, and the whole course is marked by periods of apparent 
improvement followed shortly by exacerbations. 

Chronic Intestinal Indigestion. — The general symptoms are 
those of malnutrition or marasmus, the chief of which are loss of 
weight (actual or relative), marked anemia, subnormal tempera- 
ture at frequent intervals, constant fretfulness, anorexia, sleep- 
lessness, and muscular weakness. 

The tongue is coated, as a rule, and in some instances the 
appetite may be good, but this is usually followed by vomiting, 



CHRONIC DIARRHEAS 1 65 

so that the child with anorexia holds his own with the child who 
eats well and vomits often. Vomiting can in nearly every instance 
be laid to the ignorant desire to crowd the nourishment beyond 
the child's capacity. 

Diarrhea is usually not constant, but there is an alternation 
with periods of constipation. The diarrheal stools are thin, 
containing food and some mucus, have a sour, unpleasant odor, 
and are green. In the periods of constipation the stools are 
white or gray and may be pasty or hard. They are generally 
coated with mucus and may be blood streaked. Usually asso- 
ciated with the constipation there are frequent sharp attacks of 
colic. Low irregular fever is not infrequent, and when it occurs, 
usually persists for days or even weeks at a time. 

Malaria. — Sometimes malaria will evidence itself in a child 
chiefly by an apparently causeless diarrhea. If one will always 
foster the habit of asking, "At what times did the bowels move?" 
instead of the usual one of "How often did the bowels move?" 
many of the cases which go unrecognized for a long time would 
be diagnosed at once. 

As was suggested before, the differential diagnosis will be 
considered collectively. 

The Stool. — In Tuberculosis : Almost exclusively fecal, although 
at times there may be small quantities of undigested food, and 
especially those of a fatty nature. The consistency is somewhat 
thinner than normal and there is some mucus present. Tubercle 
bacilli present ; only positive evidence. 

Chronic Ileocolitis: Almost identical with the above, but with 
the presence of undigested food more constant and not so limited 
to those of a fatty nature. 

Chronic Intestinal Indigestion: Thin stools with undigested 
food and some mucus and an odor which is not offensive, but sour. 

Malaria: Thin, offensive, and fecal, usually followed by normal 
stool later in the day. 

The Diarrhea. — Tuberculosis: Occurs for a few days at a time 
and then stops, only to recur again. Diarrhea is only constant 
toward the last. There may be colicky pain preceding the 
movement, but it is never marked. 

Chronic Ileocolitis: The diarrhea does not exhibit any tendency 



1 66 DIARRHEA 

to improve. Apparent improvement may occur after an exacer- 
bation which is traceable to some error in diet or care. Colic is 
the rule. 

Chronic Intestinal Indigestion: Alternating attacks of diarrhea 
with constipation. 

Malaria : A few loose movements within a short period, then, if 
there is another movement, it is nearly normal. Diarrhea occurs 
about the same time every day, or every other day, but in any 
event is periodical. 

The Condition of the Abdomen. — Tuberculosis : Soft and sensitive 
upon pressure until the occurrence of considerable peritonitis. 

Chronic Ileocolitis: Abdomen usually enlarged and more or 
less purled out, in strong contrast to the wasted body. 

Chronic Intestinal Indigestion: No marked change except as 
part of a general wasting. 

Malaria : Abdomen normal except for an enlarged spleen. 

General Considerations. — Tuberculosis: Usually occurs after 
the third year and is associated with evidences of tuberculosis in 
remote parts. History of infection. 

Chronic Ileocolitis: Most frequent early in life and follows an 
acute attack. There is no tendency to rise of temperature. 

Chronic Intestinal Indigestion: If any fever it is low, and 
irregular. 

Malaria: Occurs at any age, even in nurslings. Periodicity 
marked. Therapeutic test is available. 

INCONTINENCE OF FECES 

Incontinence of feces must not be m'staken for diarrhea ; this is 
barely a possibility, and yet I have seen this error made simply 
from a careless disregard of the condition of the child. It is 
common in transverse myelitis and in all paraplegic conditions 
due to an injury of the spine in the lumbar region. 

During the course of some of the acute and chronic diseases 
which cause a marked amount of prostration it may occur as a 
transient symptom, and this is especially true of typhoid fever, 
tuberculosis, cholera infantum, and some cases of acute gastro- 
enteric infection and pneumonia. It is a common accompaniment 
of all adynamic nervous conditions from any cause. 



PAINFUL DEFECATION 1 67 

The same conditions which result in incontinence may later 
bring about a condition of obstinate constipation, for the relaxed 
and inactive sphincter may not simply allow the escape of the 
contents of the bowel, but may, by its inactivity, associated with 
that of the rectum, allow the feces to mass themselves in and 
above the rectum. With lessened secretion of juices this mass 
soon becomes caked and results in a troublesome condition of 
constipation. Incontinence of feces associated with incontinence 
of urine is one of the symptoms of an epileptic convulsion, and 
helps to distinguish it from other similar seizures. 

PAINFUL DEFECATION 

Painful defecation is generally associated with rectal tenesmus, 
but this is not invariably the case. The two conditions must 
not be confused (see " Rectal Tenesmus," page 168). 

The commonest cause of painful defecation in children is 
fissure of the anus. It is of very frequent occurrence and may 
be due to several causes (injuries from syringes, the passage of 
hard, dry feces, etc.), but is always the source of much discomfort 
to the child. The fear of pain which accompanies a movement 
from the bowel results in a state of chronic constipation which 
tends to keep up the primary condition. 

The pain at the time of defecation is very severe, and it may 
persist for a considerable time after the act of defecation. General 
symptoms of a reflex nervous disturbance may be added, and may 
be so severe as to interfere materially with the general good 
condition and nutrition of the little one. 

Hemorrhoids may be the cause of painful defecation, but hem- 
orrhoids are rare in young children. Occasionallv thev are 
associated with anal fissure, and are probably dependent for their 
existence upon the condition of chronic constipation. When 
hemorrhoids are present, they are usually very small and exter- 
nally located, so that inspection is usually sufficient to detect them. 

When proctitis is present, defecation is usually painful, but this 
is generally predominated by the tenesmus which is present. 



1 68 DIARRHEA 

RECTAL TENESMUS 

Rectal tenesmus is evidenced by a constant desire to empty the 
rectum. This is associated with more or less pain, as a rule, and 
the effort to defecate is partly or wholly ineffective. It is a rather 
common associated symptom of the various diarrheas in young 
children, being most noticeable and intense in cholera infantum. 
If a diarrhea has been caused by irritant poisons, tenesmus is 
apt to be a very prominent feature. If it is associated with the 
discharge of mucus or bloody mucus without the admixture of 
feces, it is at once suggestive of intussusception. It is an impor- 
tant diagnostic symptom of other conditions, as follows: 

Proctitis. — This inflammation of the rectum is not infrequent, 
and is a prolific cause of rectal tenesmus. The prominent symp- 
toms of tenesmus, pain, and discharges of mucus from the rectum 
are usually sufficiently marked at the very beginning to allow of 
an early diagnosis. When the condition is a primary one (which 
is not the rule), the disease is early recognized, but when secondary 
(as it generally is to inflammation of the large intestine), the symp- 
toms are so masked with the original disease that no distinction 
is made unless the symptoms of the rectal inflammation pre- 
dominate. The causes are generally local ones, and the most 
frequent is the prolonged use of suppositories or enemata. 

Defecation is usually painful, while tenesmus is present inva- 
riably during the act and usually for a long time after. The 
mucus which is discharged from the rectum is jelly-like and clear, 
but at times may be mixed with feces or be passed in a cast, 
Frequently slight hemorrhage is evident. The discharge is 
generally so irritating that the skin is reddened and inflamed by it. 

If instead simply of clear mucus the discharges contain pieces 
of pseudomembrane, then the condition is known as membranous 
proctitis. This condition is usually an acute one, but its persist- 
ence is not infrequent. 

Sometimes the disease is accompanied with ulceration (ulcerative 
proctitis) , which is superficial. The ulcers are always small and 
several in number, but the mistake must not be made of suppos- 
ing the coalescence of several small ulcers to be a large ulcer. In 
these cases the hemorrhage varies considerably, one time being 



RECTAE TENESMUS 1 69 

very small, the next time being considerable in quantity. When 
the ulcerations are situated high in the rectum, the tenesmus is 
less marked, but there is always an increased reflex excitability of 
the rectum in all forms of proctitis, which results in rapid ejec- 
tion of the discharges from the rectum, and this should always 
arouse a suspicion of inflammation. 

Examination will show, in the milder forms of the disease, a 
state of mild prolapse and considerable reddening and congestion 
of the rectal mucosa. There will also be noticed an abundant 
secretion of mucus. To distinguish the ulcerative form it may 
be necessary to make a digital examination. 

Rectal Polypi. — As a rule, the first indication of the existence 
of a rectal polypus is the occurrence of continued tenesmus and 
the discharge of bright red blood with, but not mixed through, 
the stool. There is no way to make the diagnosis except by 
rectal examination. Digital exploration easily detects the 
growth, which is usually single and is pediculated. 



CHRONIC CONSTIPATION 

This condition may be said to exist when there is a lessened 
frequency in the movements, when the act of evacuation of the 
bowel is more difficult than normal, when the stool is drier than 
normal, and when the total amount of the feces is much reduced. 
It is not unusual for more than one of these factors to be present 
at the same time. The foregoing points must be considered, 
for to the lay mind constipation exists only when the bowels do 
not move as often as usual. 

The average infant at the breast moves the bowels about two 
or three times daily, but there are occasional instances in which 
an infant will have but one evacuation daily, and if observed over 
a protracted period, there are no untoward effects ; in such a case 
constipation cannot be said to exist. On the other hand, the 
bowel may be evacuated with normal frequency and yet the 
amount be so small that constipation actually exists, and shows 
its effect upon the general condition in time. The same thing 
applies if the movements are normal in number and amount, but 
deficient in fluid, causing hard, dry feces. 

The estimation of the time required for the passage of the food 
through the gastro-intestinal tract may at times be very impor- 
tant. A pure milk diet occupies from thirty to forty hours in 
passage from mouth to rectum. The simplest means of testing 
the time occupied is to give one meal stained with either char- 
coal or, better yet, with carmin, and then watch for the first 
black or red stool. 

Occasionally we observe an infant suffering with a latent con- 
stipation with some toxic svmptoms, and still having one or more 
evacuations every day, and the cause is not suspected until an 
estimation is made of the time of the passage of food through the 
digestive tract. Further than this, such an estimation is useful 
in diagnosis of other conditions, as shall be shown later. 

170 



CAUSES OF CHRONIC CONSTIPATION 17 1 

The Causes of Chronic Constipation. — These may be divided 
into causes within and causes outside the bowel. 

Of the first division, we have the position and development of 
the infant's intestines and rectum favoring bowel inactivity. 
Early in infancy the rectum is placed more in the abdominal 
cavity than in the pelvic, and occupies a more or less vertical 
position. The ascending colon is very short and the large and 
the small intestines are both proportionately longer than in the 
adult. The proportionately greater length tends to lessened 
peristaltic movement; lessened movement tends to slow passage, 
therefore to dryness of the fecal mass. The proportionately 
larger surface also favors absorption and consequently produces 
dryness. 

The glands of Brunner and Lieberkuhn are not fully developed 
in early life, and as they are active factors in bowel activity, 
this underdevelopment favors constipation from dryness. The 
amount of intestinal juice may be sufficient, but it may be too 
viscid. There may be a mechanical obstruction in the intestine, 
or some condition which diminishes the lumen of the gut. 

Of the causes which are not within the intestine, we have 
constipation as an accompaniment of many of the acute and 
chronic diseases. Fever naturally diminishes the amount of 
fluid in the body, and in the diseases accompanied with elevation 
of temperature, unless diarrhea is the usual concomitant, con- 
stipation is the rule. 

Any disease, either acute or chronic, which considerablv lowers 
the muscular tone also diminishes peristaltic movement. Some- 
times the peristaltic movement is so incomplete that the mass 
is passed through the intestine very slowly and becomes dried. 
Fear of pain which is caused by the act of defecation (as in anal 
fissure) will result in chronic constipation. 

The chief of all causes is the diet. In nurslings this is usually 
due to a lack of fresh water; in bottle-fed babies, to a deficiency in 
fat and an excess of proteids. Then, again, it may be due to a 
lack in the volume of the residue of food in the intestine. Too 
much casein or starch and too little sugar may be the cause, or 
it may be due to the constant use of sterilized milk. Habit 
plays a much more important role than is commonly supposed. 



172 CHRONIC CONSTIPATION 

and in the production of a chronic constipation it holds second 
place to diet. Occasionally it is a constitutional tendency. 

The symptoms are at times purely local for a while, but this is 
unusual. Generally the nutrition and general health are more or 
less affected. There may be simple flatulence, accompanied or 
unaccompanied by colicky pains, or the irritating mass in the 
intestine and rectum -may excite some inflammation. When 
inflammation occurs, it is evidenced by tenderness and by the 
presence of mucus and perhaps blood in the stool. 

The absorption of toxins causes, in susceptible infants and 
children, nervous symptoms of a varied and sometimes a severe 
type. Usually these symptoms are cephalalgia, disturbed sleep, 
peevishness, dullness, and associated signs of intestinal disorder. 
A slight rise in temperature sometimes accompanies these symp- 
toms, and this is especially true of delicate infants. 

The diagnosis of the condition alone is not sufficient; there 
must be a determination of the cause, and, if possible, of the site 
of the trouble. The diagnosis of the first must take into consider- 
ation everything which affects the normal state of the bowel, 
and this involves primarily a thorough examination into the diet 
and habits. 

With regard to the site of the trouble, a test-meal is valuable. 
We know that normally the food of a nursling requires from 
thirty to forty hours to pass from the mouth to the rectum. 
Now, if one meal is colored with carmin or charcoal and the time 
of the passage of the first red or black stool is noted, we can readily 
estimate the time occupied in passage through the whole tract. 
If the time is close to normal, it indicates that the lower or middle 
portion of the large intestine is at fault, and that peristalsis is 
not much increased in the small intestine. 

White or gray stools, offensive breath, and flatulence all indi- 
cate affection of the small intestine. When the insertion of a 
suppository is immediately followed by a movement, it is indica- 
tive that the rectum is at fault. 



INTESTINAL PARASITES 

Until very recently many of the ills of childhood were attrib- 
uted to the presence of intestinal parasites. The laity are still 
firmly convinced in regard to this matter, and all sorts of trouble 
is laid at the door of the "worms." The pendulum has now 
swung as far the other way, and it is not infrequent to find writers 
denying that any appreciable symptoms are due to the presence 
of intestinal parasites. Their claim is based largely upon the 
fact that at autopsy it is not uncommon to find these parasites 
present in large numbers, while during life nothing occurred to 
give evidence of their presence. But, on the other hand, there 
are innumerable instances where the expulsion of intestinal worms 
during life has been immediately followed by the disappearance 
of symptoms which could be accounted for in no other way than 
by their persistent presence. 

The marked tendency of the laity to dwell upon the importance 
of worms (and also dentition) as causative factors of all kinds of 
conditions has often led the physician to take the other extreme, 
denying that any symptoms are caused by them. To deny that 
the parasites have any influence in the production of certain 
symptoms is to deny the experience of many careful observers; 
it places a ban upon the findings of experienced hematologists 
and shows an ignorance of the highly sensitive organism of the 
child, which renders it so susceptible to reflex influences. 

Of course, when it comes to a question of positive diagnosis, 
the parasite or its egg must be seen, but in nearly every instance 
they are observed because there has been some svmptom which 
has led to a suspicion of their presence and some measures have 
therefore been instituted for their removal. 

Oxyuris Vermicularis (Pin- worms). — This is by* far the most 
common variety of parasite which inhabits the intestine of chil- 
dren. In appearance it is like a thread, white in color, and from 
one-half to one or more centimeters in length. The female is 
about twice the length of the male. Pin-worms usually inhabit 

173 



174 



INTESTINAL PARASITES 




Fig. 42.— Oxy- 
uris vermicularis 
(natural size). 



the large bowel, migrating, as a rule, during the early evening 
toward the rectum and making the anus their feeding-ground. 
The symptoms which are present are usually due to this habit 
of the parasite. Shortly after the child has been 
put to bed there is more or less intense itching 
about the anus, and sometimes about the genitals 
(the latter especially in girls). This irritation 
causes other symptoms which vary with the 
susceptibility of the child's nervous system to 
reflexes. The usual symptoms are restlessness, 
wakefulness, with scratching at the anus, in- 
continence of urine, and at times vomiting. In 
such cases an inspection of the anus will almost invariably dis- 
close the presence of some of the worms. If not, then an enema 
of warm water and quassia will bring them into view in large 
numbers. 

Ascaris Lumbricoides (Round- 
worms). — This variety of para- 
site very closely resembles the 
common earth-worm. It is from 
three to twelve inches in length 
and of pale pinkish-white color. 
The shape is round, with gradual 
tapering toward both ends. The 
whole body of the worm is marked 
by fine transverse lines or rings. 
After a short exposure to the air 
the color of the parasite changes 
to a dark, dirty white. 

The usual habitat of this worm 
is the upper part of the small in- 
testine, but their migratory habits 
are marked, so that they are led 

elsewhere. Occasionally they travel into the lower bowel, to the 
stomach, vagina, appendix, the eustachian tube, etc. Expulsion 
generally takes place per rectum, but it is not unusual to see 
them expelled by vomiting. 

Of this worm and its egg it may be said that, above all other- 




Fig. 43. — Ascaris lumbricoides. 



INTESTINAL PARASITES 



75 





varieties, it must be seen to make the diagnosis positive. The 
symptoms are so indefinite, being almost entirely reflex, and 
varying with the migrations of the parasite, that a diagnosis is 
usually only made by exclusion. This is later confirmed by treat- 
ment. The production of an excessive amount of intestinal 
mucus is so often associated with the presence of this parasite 
that its existence should always excite suspicion. 

Teniae (Tape- worm) . — This may inhabit the bowels of children 
of any age ; nurslings are not exempt, and cases have been reported 
as occurring in the newly born. It is not essential for diagnosis 
that the different varieties of tape-worm 
be recognized, so that mention will only 
be made of the common characteristics. 

They are all similar to each other in that 
they grow by segments, the different seg- 
ments constituting a chain. The smallest 
segment is that which is nearest to the 
head, and that one is so minute that it 
is invisible to the naked eye. Growth is 
accomplished by the addition of seg- 
ments to the head, so that the retention 
of the head upon the mucosa of the bowel 
means the continued development of the 
worm. 

The upper part of the small intestine is 
the usual situation for the worm. Full 
attainment of growth is generally accom- 
plished in from eight to twelve weeks, and then there begins the 
throwing-off of the segments, which may be detected in the 
stools. An occurrence of this kind makes the diagnosis simple, 
provided that no undue haste is shown, for it is not infrequent 
that mucoid stools are mistaken for segments of the worm. 

The symptoms are very indefinite and are usually those of a 
persistent malnutrition despite a ravenous or a capricious appe- 
tite. Anemia is usually marked and there are apt to be indefinite 
abdominal pains and attacks of gastrointestinal disorder which 
cannot be clearly accounted for. Microscopic examination of 
the feces may be made in cases where there is much doubt ; this 
will reveal the ovum if the worm be present. 



a b 

Fig. 44.— Teniae — (a) head 
and first segments; (&) mid- 
dle segments. 



THE CRY AND THE VOICE 
THE CRY 

Crying is not expressive of the emotions until near the end of 
the third month of life, and about this time tears are observed to 
accompany the cry. It is a matter of interest to observe that 
the tears, perspiration, and a free flow of saliva all appear at 
about the same time of life. 

A lusty cry directly after birth is a most welcome sound, not 
alone as a sign that the most difficult stage of labor is terminated, 
but it indicates the undoubted respiratory vigor of the infant. 

Weak, feeble cry at birth, or absence of any crying at this 
time, is at once indicative of — (a) the general feebleness of the 
infant, (b) pulmonary atelectasis, or (c) congenital heart lesions. 
The first is self-evident, the second being indicated by lividity 
and infrequent or absent respirations, and the last by the general 
pallidity and weak fluttering heart. 

Loud cry, occurring several times during the day or night, 
arising suddenly and stopping just as suddenly, especially after 
the expulsion of gas from the stomach or bowel, is strongly indica- 
tive of colic from indigestion. During the act of crying the infant 
is very apt to throw its legs about or to rub them violently together, 
but this is not any more characteristic of this cry than it is of any 
violent crying spell. If due to colic, it is at once relieved by an 
enema, and the evacuations may give evidence of feeble digestion. 
If the same character of a cry is present with a rise of temperature 
to ioi° F. or over, it is proof that we are not dealing with a 
simple dyspeptic colic, but that there is some associated condition. 

Continued loud cry, with a stiffening of the body and the head 
being thrown backward, may be due to one of two things — 
temper or acute pain. The first is very rarely seen before the 
fourth month of life, and is apt to occur under similar circum- 
stances. To properly diagnose the latter cause, it is necessary to 
examine the infant and its surroundings for the cause of the dis- 

176 



THE CRY 177 

tress. Loosened pins and the bites of insects are a prolific cause. 
If the pain is relieved by the ingestion of food, but after a time 
returns again, it is evidence of some digestive condition causing 
the pain. 

Continued, suppressed cry should attract attention to condi- 
tions in the head, the abdomen, or the chest. If pain is caused by 
the use of the abdominal muscles or those of the chest, the child 
will try to suppress all motion. If venous stasis increases pain 
in the head, the infant will refuse to move that member freely, 
and tries to suppress the cry. 

Continued but low cry may indicate several conditions: 

(a) With loss of weight, but no appreciable rise in the tempera- 
ture, the voiding of a much lessened amount of urine, and, as a 
rule, with constipation, indicates that the infant is hungry. This 
may be corroborated by an examination of the milk, or testing 
what effect upon the condition a feeding or two with a modified 
milk will have. When the cry has been due to a chronic state of 
hunger, one such feeding will make the child restful. Sometimes 
the infant may vigorously suck the fingers, but this is not a con- 
stant feature. 

(6) When more forcible an hour or two after nursing and 
associated with occasional attacks of colic, it indicates that the 
cause is chronic intestinal indigestion. 

(c) With progressive prostration (which is more marked in 
young infants) and with a tone to the cry which is a sort of a thin, 
crowing, quacky sound, points to the existence of retropharyngeal 
lymphadenitis. 

(d) With progressive emaciation and the cry being quite hoarse 
in character would suggest hereditary syphilis, if there was a 
persistent rhinitis of a more or less severe type and an old look 
to the face of the infant. 

(e) After the subsidence of the acute symptoms of several 
diseases, as cholera infantum and chronic ileocolitis, there may 
be a low continued cry which is almost a moan ; but this cry occurs 
too late to be of any special value. 

Short violent cry may be due to several factors: 
(a) Occurring at night, in an older child who awakes suddenly 
with fright, it is indicative of night terrors. If the child inva- 



I78 THE CRY AND THE VOICE 

riably gives the same cause for the nightly attacks over a long 
period, it indicates a tendency to epileptiform seizures. 

(b) Increased upon pulling at the ear or by movements which 
affect the head suggests the probability of inflammation of the 
ear. In the presence of an acute inflammation of the ear the 
mere act of sucking will cause pain and this type of crying. There 
is usually some elevation of temperature. 

(c) With a shrill character and following or associated with the 
act of coughing or sneezing, it points to acute pleurisy. 

(d) When very piercing in its character, very sudden in its 
onset, and almost simultaneous with the act of vomiting and 
associated with marked prostration quickly following, it should 
lead to an examination for intussusception. 

(e) While in a somnolent condition it is evidence of hydrocepha- 
lus or hydrocephaloid. 

(/) Occurring during defecation (due to actual pain) or just 
previous to the act (dread of pain), and associated with persistent 
constipation, it is almost certainly due to fissure of the anus. The 
same thing happening during the act of urination indicates that 
there is a spasm of the bladder, the passing of some fine calculi, or 
it is occasioned by phimosis. The administration of appro- 
priate treatment quickly clears up the first, the examination of the 
diaper shows evidence of the second, and examination of the penis 
clears up doubt as to the latter. 

Crying which occurs only when food is offered would indicate 
that the child was unable to nurse (and this might be due to causes 
in the nose or mouth or to faults in the apparatus used in nursing) 
or that nursing caused pain. The cry of acute gastro-enteric 
infection is of a restless type, with intervals during which the 
infant sleeps quietly, but these last only a few moments. In 
pneumonia the cry is apt to be short and catchy. In meningitis 
we may encounter a sharp, piercing, nocturnal cry, but this is 
true also of chronic bone disease. In marasmus there is a con- 
tinual whine; the child is seldom at ease. 



THE VOICE 179 

THE VOICE 

The voice in this section will be considered as an articulate 
sound emitted from the mouth and consisting of one or more 
distinct syllables. 

Loss of voice and hoarseness are both dependent upon some 
interference with the normal functions of the vocal cords. 

Acute. — In nearly every instance the cause will be found to be 
some inflammatory condition of the larynx; the ordinary catarrhal 
inflammation being the most common, and next in frequency 
come those which are the result of diphtheria, rubeola, and variola. 
The prolonged use of the voice is sometimes responsible for it, but 
this is unusual in childhood. A deep, hoarse voice associated 
with a harsh cough may be the first indication of post-diphtheritic 
paralysis. 

Chronic. — Hereditary syphilis should be the first thought, for 
it so frequently is at the root of these cases. Other than this, 
one must remember the possibility of cicatricial stenosis and 
impacted bodies in the larynx. 

Nasal Voice. — This may be of two kinds — the open nasal and 
the closed nasal. 

The open nasal is due to non-closure of the nasopharyngeal 
opening by the soft palate. Usually the cause is a paralysis, and 
generally this is post-diphtheritic. Syphilitic ulceration is a 
possible but a rare cause. Congenital cleft palate causes it. 

The closed nasal is due directly to nasal stenosis. When acute, 
it is indicative of coryza or the introduction of a foreign body. 
It accompanies follicular tonsillitis, pharyngitis, and retropharyn- 
geal lymphadenitis. Chronically, it indicates adenoids, but hyper- 
trophic rhinitis and polypus may cause it. 



THE COUGH 

There are two broad divisions which we may make of the 
symptom cough, and these are those which are respiratory (due 
to some inflammation of the trachea, larynx, bronchi, lung, or 
pleura usually) and non-respiratory coughs (which are due to all 
other causes). Of the non-respiratory coughs, there must be 
included all coughs due to the various deformities and inflamma- 
tions of the nasal cavity and of the pharynx, which act reflexly 
in causing the symptom of cough. Then there must be included 
irritations of the tongue and diseases of the ear and irritations of 
various portions of the body which are responsible for the act 
of coughing. In young children habit plays an important part 
in the persistence of a cough. 

The act of coughing is produced by a reflex mechanism and the 
avenue of conduction is usually through the pneumogastric 
nerve. The act of coughing is started with a more or less deep 
inspiration, which is immediately followed by a contraction of the 
respiratory muscles, which forces the air against a closed larynx. 
The force of the current of air is sufficient to separate the vocal 
cords, permitting the air to escape with much violence, and this 
constitutes the act. The soft palate shuts off the nasal cavity, 
so that the offending material, if there be any, is brought into the 
mouth. 

The amount of stimulation which is necessary to produce the 
act varies widely with different individuals, and this depends 
largely upon the general state of the nutrition. But it may be 
broadly stated that acute inflammations of the mucous mem- 
branes of the larynx, of the posterior portion of the trachea, and 
of the bronchi very readily excite the act, while chronic inflamma- 
tions of these same portions of the body, any disease which lessens 
nerve irritability, and certain drugs diminish the tendency to 
coughing. 

Under all conditions but one coughing is invariably harmful 

1 80 



CHARACTER OF THE COUGH l8l 

to a child ; that one exception is when the act serves in clearing the 
air-passages of offending material. Under any conditions the act 
of coughing increases intrathoracic pressure, interferes with the 
free flow of the venous blood in the chest, raises the blood-pressure, 
distends the lungs, and is more or less exhausting, so that it is 
readily seen that it cannot but be harmful. 

The character of the cough itself is the thing which is of most 
value in diagnosis. 

Dry Cough. — Dry cough occurs when there is some irritation 
which cannot be removed. It occurs with most frequency during 
the early stage of acute bronchitis, and at that time may be either 
slight or constant. The voice invariably remains clear, and this 
is an important diagnostic point ; for if associated with substernal 
soreness, the diagnosis of acute bronchitis is almost certain without 
further signs. 

In bronchopneumonia the cough is usually incessant and 
without expectoration, even in older children. A persistent and 
dry cough with or without a sensation of tickling in the throat is 
frequently caused by an elongated uvula, and such a cough is 
generally more severe when the recumbent position is assumed. 
An examination soon determines this as a cause of the cough, for 
the uvula is usually found to lie against the base of the tongue. 

In the instances in which there is a history of more or less 
chronicity of the cough following an attack of bronchopneumonia, 
it is very suggestive of the fact that the process has become 
chronic. If chronic, dry, and persistent, and with a tendency to 
become worse during the night, and accompanied with even the 
slightest catarrhal symptoms in which the eyes participate, it is 
strongly suggestive of pertussis. A chronic dry cough which is 
short and noticeably worse at night or in the early morning is 
indicative of anemia. 

Moist Cough. — This character of cough is most typically 
observed during bronchitis when resolution has set in. In older 
children it is attended with the expectoration of mucus which is 
mucopurulent or purulent. The cough becomes moist also in the 
later stages of bronchopneumonia, pneumonia, phthisis, and 
pertussis. 



1 82 THE COUGH 

Hacking Cough. — A cough with a distinct hacking character 
may occur in some cases of bronchopneumonia in infants and is 
not of good import, as the little one's vitality is somewhat lessened 
by such an occurrence. 

A chronic hacking cough which is markedly increased from 
apparently very slight causes would at once suggest the possi- 
bility of chronic pleurisy. A single, dry hack, frequently repeated, 
indicates one of two conditions — phthisis or a dry post-nasal 
catarrh. A short, somewhat hacking cough, not so frequently 
repeated, but persistent in its course, may be due to foreign 
bodies in the ear. 

Laryngeal Cough. — This cough is usually easily distinguished 
because of its hoarse and dry character. In acute laryngitis it is, 
as a rule, dry, almost constant, and is exaggerated by speaking, 
crying, the ingestion of fluids, or upon deep inspiration. It is 
usually accompanied with either a whistling, metallic, or brassy 
sound. In chronic laryngeal affections the cough is dry and also 
hoarse. 

Laryngeal cough naturally always indicates some affection of 
the larynx, and membranous and spasmodic laryngitis are the 
most frequent ones. Ulceration may cause it, but it is rare in 
childhood. 

Paroxysmal Cough. — This is at once indicative of pertussis, 
and one should always be suspicious of this disease until it can be 
absolutely excluded as the cause of the paroxysms. It may be 
of any intensity and character, and the value of such a cough in 
diagnosis lies simply in its distinct occurrence in paroxysms. 
There is no greater fallacy than that which insists that the child 
must whoop before the case can be considered one of pertussis. 
While indoors the paroxysms are more pronounced and frequent. 

In all conditions in which there is an increased secretion, and 
particularly that of a tenacious character, there is apt to be 
paroxysmal coughing until the offending material is expelled. 
This is often observed in the later stages of bronchitis and of 
phthisis. 

Suppressed Cough. — This is usually due to some painful 
condition which the act of coughing exaggerates, so that it is seen 
sometimes during pneumonia, and to a degree in pleurisy, which 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 1 8 



is often marked. If a disease which causes coughing is compli- 
cated by either peritonitis, abdominal diseases causing pain on 
motion, or any other such condition, the cough which is present 
is changed to a suppressed cough. 

Cardiac Cough. — This is a short, dry, and hard cough which 
is worse at night and in the early morning. It is almost identical 
in character with the cough of the anemic child, but there is a 
difference, for although children affected with it are pale and 
haggard and the cough is entirely absent during the day, there 
is nothing about the child, as far as the respiratory organs are 
concerned, to suggest a cause, and the other symptoms of anemia 
(besides the paleness) are absent. Such a cough is usually present 
very early in hypertrophy and dilatation of the heart. In the 
later stages there is generally a rather profuse expectoration, 
which may be blood-streaked. 

Inability to Cough. — Either total inability or a marked 
weakness of the act of coughing may be due to disease affecting 
the motor nerves, the general musculature, or the central nervous 
system. Then, again, overstretching of the diaphragm by an 
accumulation of fluid or by growths may diminish its contractility 
and so lessen the ability to cough. Inability to cough, when it 
occurs during either an acute or a chronic illness, is of evil import, 
indicating impending collapse. 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 

Pertussis. — This is a contagious disease which exempts no 
age, but it is most frequent early in life and especially during the 
first six years. There are three rather distinct stages — the 
catarrhal, the spasmodic coughing, and the resolving stage. 

The catarrhal stage usually begins with a cough which does not 
distress or annoy the child. An examination at this time shows 
nothing abnormal in the chest, but as the pharynx is reddened 
and inflamed, the case is usually considered as a simple pharyn- 
gitis. Quickly following this there is some slight nasolaryngeal 
catarrh and there may be some rise in temperature (ioo° to 
ioi° F.). Within a very few days the rise in temperature dis- 
appears, but the catarrh and the cough persist. At first the cough 



184 THE COUGH 

is single, but it quickly loses this character and assumes the 
characteristic one of repeated coughs occurring in distinct spells, 
and sometimes the coughs following one another so rapidly that 
the child cannot properly respire until the spell is over. 

The transition of the catarrhal into the spasmodic coughing 
stage is gradual, and usually by the middle of the second week 
the coughing in spells is distinctly established. The paroxysms 
are more severe at night, because at that time the child is usually 
under conditions which rob it of the free supply of fresh air which 
it has enjoyed during the day. If the child is kept housed up, 
the paroxysms are no worse at night than they are during the 
day, being severe at both times. The influence of fresh air is 
very noticeable during the summer months, when children with 
the disease are allowed to sleep near open windows, resulting in a 
marked reduction in the severity and frequency of the paroxysms. 

The cough is usually characteristic in itself ; the attack is sud- 
denly violent, the coughs following one another with uninterrupted 
frequency until there is but little air in the lungs. The child's 
face is then cyanotic (parents generally describe it as being very 
red), and the child takes a deep inspiration through a glottis which 
is spasmodically closed, and the air forcing its way through the 
narrowed opening produces a loud, stridulous whoop. This 
may be repeated from one to ten times, and then end with vomit- 
ing or the expectoration of a plug of viscid mucus. If the par- 
oxysms are less than ten in twenty-four hours, the disease may 
be considered mild; if less than fifteen, moderate; and if over that 
number, it is severe. 

After three or four weeks of the second stage there is a gradual 
merging into that of resolution. In this last stage the paroxysms 
become progressively lessened, the vomiting ceases, the viscid 
mucus becomes less tenacious, all of the symptoms improve, 
and after three weeks the cough has usually entirely cleared up. 
The tendency now from this time on is to recurrences of pertussis- 
like coughs from slight causes. 

If the pertussis is of moderate or of severe intensity, the face 
of the child is usually somewhat swollen and bloated looking, and 
the eyes are suffused, and during the coughing spells may be 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 1 85 

streaming. Generally there is more or less conjunctival eechy- 
mosis. 

The diagnosis may be difficult at first, and the possibility of 
mistaking pertussis for pharyngitis has been spoken of. When 
there is a rise of temperature and the catarrhal symptoms are 
pronounced, there is a probability of the disease being mistaken 
for influenza of a mild type. But influenza is not so protracted 
(the catarrh usually beginning to clear on the fourth day at least) , 
the fever and the cough which are present ameliorate with the 
catarrhal symptoms, and the prostration is out of all proportion 
to the severity of the symptoms. 

Sometimes in bronchial adenopathy there is a spasmodic cough 
which simulates that of a mild pertussis, but the whole course and 
history of the two are distinct. In the former condition the 
cough begins as a chronic bronchitis (later only does it become 
anything like pertussis cough), and the physical signs are then so 
pronounced that there is no reason for error. 

If the following points are considered, the diagnosis of pertussis 
is rendered easy and its differential diagnosis is simplified: (a) 
It is contagious (several members of a family or of a neighborhood 
are affected usually). (6) The catarrh does not extend below 
the largest bronchi, and the eyes are involved, (c) Examination 
of the chest is negative, despite the severe cough, (d) The cough 
is distinctly paroxysmal, no matter what its mildness or severity, 
and is made worse by housing, (e) The coughing spell usually 
ends with the expectoration of viscid mucus or with vomiting. 

Foreign Bodies in the Larynx or Trachea. — Some children 
are constantly in the habit of placing articles in their mouths, 
and at that time a fit of coughing, laughing, crying, or sneezing 
may result in the escape of such articles into the larynx or the 
trachea. The lodgment may be in the ventricles, and if so, this 
will produce coughing which generally quickly results in the 
expulsion of the offending body. 

There may, however, be a spasmodic condition of the glottis 
induced, and this will result in retention. Other times the article 
is passed into the trachea or into the bronchus, where there 
may be an impaction of it. At other times the obstruction nun 
be due not to any article which the child has placed in the mouth. 



i86 



THE COUGH 



but lumbricoid worms may be the offending mass, although the 
migrations which lead them thus far are rare. 

The first symptoms are cough, aphonia, and dyspnea. The 
cough is most severe, and may be so pronounced and so persistent 
that the child is rapidly exhausted by it. Naturally it is of very 
sudden onset and almost at once assumes the violence which is 
its characteristic. The aphonia and the dyspnea both vary in 
degree with the size of the foreign body as well as with its situation. 
Sometimes there is a sudden letting-up of all of the symptoms, 

and this may mean that the 
body is dislodged or that it 
has become impacted in some 
less irritating part. 

Usually with the history 
and the suddenness of the 
symptoms the diagnosis is 
clear, but it occasionally offers 
some difficulties. There may 
be no history (as when the 
child is asleep, when the body 
escapes from the mouth, and 
when worms are the cause), 
and the symptoms may not 
be severe. Then there is 
danger of mistaking the con- 
dition for an attack of acute 
laryngitis, or if it is mild and 
more persistent, for laryngeal 
diphtheria. 
If a foreign body is of a very irritating nature or if it is long 
retained, then it may result in trachitis. 

Trachitis is a rare disease and one which is of short duration, 
when it is not associated with inflammation of the bronchi or the 
larynx. The chief symptoms are a tickling sensation in the throat, 
which is accompanied with more or less burning or actual pain 
upon inspiration of chilled air. There may be some expectoration. 
Except for the absence of any rales, it cannot be distinguished 
from a mild attack of bronchitis. The history of a cause is of 
value. 




Fig. 45. — Position of the trachea and the 
primary bronchi. It will be noted that the 
right bronchus is slightly longer than the left 
and has a less acute dip. 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 187 

Acute Bronchitis. — Cough is the essential feature of any 
bronchitis, and is usually the chief feature. All the other symp- 
toms are of less diagnostic importance, as they differ so widely 
in their constancy and severity. They cannot be disregarded, 
for they are important, but nevertheless the cough is the one 
constant symptom of the disease. 

The cough may be constant and severe, or it may be slight, but 
the voice remains clear in an uncomplicated case. In the begin- 
ning the cough is dry and ineffectual. As the symptoms other 
than the cough are variable and inconstant, I think it advisable 
to describe somewhat in detail the different types which we 
observe in childhood, and these are the mild and severe forms in 
infancy and the mild and severe forms in older children. 

Mild Infantile Form. — The onset is gradual and is usually 
preceded by catarrhal inflammation of either the nose, the phar- 
ynx, or the larynx, or, as it is usually expressed by the parent, 
"the little one had a cold in the head." The cough may not 
be severe, but is ineffectual and apt to be quite constant. There 
is, of course, no expectoration at this or any other stage of the 
disease, as infants invariably swallow any mucus which may be 
brought up into the mouth by coughing. 

The respirations are increased to forty or fifty a minute, and 
are within a day or two accompanied by a more or less pronounced 
rattling sound, which the laity describe as "wheezing or rattles 
on the chest." The infant becomes restless and irritable, owing 
to the discomfort caused by the disease. The temperature for 
the first twenty-four or forty-eight hours usually ranges some- 
where between ioo° and 101J F., and then subsides to below 
the 100 ° mark. At first constipation is the rule, but this is 
usually quickly followed by a mild diarrhea, with loose greenish 
stools. 

If the infant is one in fair health, and without evidences of 
rachitis, the general symptoms are always mild, but if weakened 
from any cause, and especially if the little one is rachitic, there 
may be higher temperature, more rapid respiration, vomiting, 
and the development of cerebral symptoms which may prove 
alarming. 

The physical examination usually shows: Palpation— generally 



i88 



THE COUGH 



marked bronchial fremitus. Auscultation — the presence of dry, 
sonorous rales over the whole chest during the first day or day 
and a half, when they give way to coarse mucous rales which are 
detectable everywhere in the chest, but are most distinct between 
the scapulae and in the infraclavicular region. 

The usual duration of this form is from seven to nine days and 
relapses are common. 

Severe Infantile Form. — The onset is generally gradual, with the 
severe symptoms occurring after a very few days' illness, but 
occasionally there is a sudden onset. The cough is hard and 
teasing, but is generally short. The respirations are increased to 
fifty or seventy a minute, or may exceed this number at times. 
The temperature is not as high as would be expected from the 



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Fig. 46.— Chart of the temperature (— ) and respirations ( ---) in acute bronchitis. 

Child ten months old. 



evident severity of the disease, and usually ranges between 100 ° 
and 102 F., but may increase to 104 . 

The general symptoms are severe, and cyanosis is sometimes 
quite marked in ill-nourished infants and is almost always slightly 
present in all infants. Dyspnea is well marked, and the relation 
of the severity of the dyspnea is rather to the respiratory rate 
than to the temperature. 

The physical examination shows: Auscultation — at first the 
chest is filled with sonorous and sibilant rales, but within twenty- 
four hours these are displaced by moist rales, which are either 
fine or coarse, according to the site of their production (the large 
or the medium-sized tubes). On inspiration the rales are apt to 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 1 89 

be quite loud and wheezing in character and respiratory murmur 
is enfeebled. The rales are heard in all parts of the chest, but 
their greatest intensity is in the back. Fine rales are the first 
ones to disappear, and indicate that the disease is coming to an 
end. 

Sometimes the disease appears to be following the usual course, 
when suddenly there will occur the development of symptoms 
which, if they do not receive prompt relief, result in the death of 
the infant. There is suddenly no disposition to cough, and this 
may be associated with an indisposition to cry also; the pulse 
becomes rapid and weak, the respiration is even more accelerated 
and becomes irregular and shallow, the skin is markedly cyanosed, 
and may be bathed in cold perspiration. Stupor may then come 
on and be followed quickly by convulsions and death. 

The course of the disease is short, the severe symptoms usually 
persisting for two days (rarely over three days), from which 
time on there is a gradual clearing up of all of the symptoms. 
Relapses are not frequent, but extension to the fine bronchi may 
occur. 

Mild Form in Older Children. — The onset is one which shows 
nothing definite; there may be slight constitutional disturbance 
for a day, but if there is, it is so slight that no attention is paid 
to it. 

The first thing which attracts attention is the cough, which in 
the beginning is hard, tight, and exhausting and accompanied 
by considerable substernal soreness. Such a cough is usually 
more severe at night. Later on the cough becomes much looser 
and there is an abundant expectoration of a white viscid mucus 
which rapidly becomes yellowish and mucopurulent. 

The temperature is normal or there may be an insignificant 
elevation, and there are no general symptoms of anv moment. 
Auscultation shows coarse rales, which are at first dry and then 
rapidly become moist and are heard over both sides of the 
chest. The usual course is from eight to ten days, and the tend 
ency of neglected cases is to run into a subacute form which 
persists sometimes for weeks at a time. 

Severe Form in Older Children. — The onset is rather sudden, and 
with the rapid appearance of a hard, tight cough which is associated 



190 THE COUGH 

with substernal soreness. There is usually a chill, which is fol- 
lowed by an elevation of temperature which at first may range 
from 10 1 ° to 104 F. The temperature generally reaches its 
maximum height within the first twenty-four hours, and then 
persists for two or three days. Expectoration is a very early 
occurrence and is usually very abundant, the first ejected material 
being blood-streaked, as a rule. 

The general symptoms are severe, w T hile the temperature is 
much elevated. Auscultation shows coarse rales, which are 
similar to those observed in the mild form, but they are associated 
with fine rales also, which are at first dry but rapidly become 
moist. Wheezing rales are heard on inspiration. 

The diagnosis of acute bronchitis is usually easy. Catarrhal 
inflammation or irritation of the mucous membranes of the trachea, 
the pharynx, and the bronchi is always associated with cough, so 
that one must distinguish these in the early stages. If upon ex- 
amination of the chest there is found no dullness, then we are 
reasonably certain that we are dealing with bronchitis, pharyngitis, 
or a reflex cough. If the posterior pharyngeal wall is absolutely 
normal and there is absence of any rhinitis, then we know that the 
trouble is not in the pharynx (it is necessary to exclude the rhini- 
tis, for mucus flowing down over the pharyngeal wall will excite 
troublesome cough). All of the causes of reflex cough must then 
be considered and excluded as factors. 

Next to the occurrence of cough, the most important datum is 
given by auscultation. Both dry and moist rales are heard in 
the chest. At first we have the sonorous and the sibilant, being 
replaced later by fine or coarse moist and bubbling rales in the 
stage of abundant secretion. 

To go more into detail, these are indicative as follows : 

If coarse and sonorous rales are heard, then the larger bronchi 
are involved, because rales of that type are formed in cavities 
or tubes with a large caliber. 

On the other hand, there may be absence of appreciable rales 
when the secretion is very small. In such instances dependence 
is placed upon the character of the cough and the fever until other 
symptoms develop. If it is possible to detect substernal soreness, 
then this aids very materially in the diagnosis. 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 191 

If the affection is of the medium- sized tubes, then dry and moist 
rales are always present uniformly. But if the amount of secre- 
tion be small, then we depend upon the presence of coarse vesicular 
breathing and an indefinite respiratory murmur. 

When the affection is of the smallest tubes, we may have a 
whistling respiration because of the narrowing of the tube by 
inflammatory swelling. When a secretion is formed, small rales 
are present. 

If bronchitis develops during the course of laryngitis or simulta- 
neously with it, then a great difficulty is encountered, for the loud 
stenotic breathing drowns out every other sound. 

If the breathing is much accelerated, then we are justified in 
suspecting the development of bronchitis. This is emphasized if 
the cyanosis is more marked than we would naturally expect with 
the degree of stenosis. The main point is in the beginning, that 
accelerated breathing is persistent in bronchitis. 

A few words in regard to the etiology cannot be out of place, 
for the consideration of it is sometimes of considerable value in 
diagnosis. No age is exempt, but the largest number of cases 
occur during the period of infancy. The explanation is found in 
the greater prevalence of predisposing and exciting causes at this 
time of life. These are partly anatomical and largely nutritional. 
Then, again, bronchitis is the common accompaniment of all of the 
acute infectious diseases, and is also frequently associated with 
disorders of the intestinal tract. 

Briefly stated, the more common causes are inflammations of 
the upper air-passages, systemic poisoning from infectious diseases, 
intestinal disturbances, rachitis, and adenoid vegetations. 

Chronic Bronchitis.— If attacks of acute bronchitis are 
neglected or they are frequently repeated, then chronic bronchitis 
is apt to supervene. Other than this, it may follow as a sequela 
to the acute form which accompanies many times the acute infec- 
tious diseases, and especially influenza and rubeola. Then all 
conditions which favor mechanical pulmonary stasis favor the 
production of chronic bronchitis. 

Like acute attacks of the disease, its development is strongly 
influenced by nutritional wrongs. It is not a common condition. 
and especially in the very young, in which particular it differs 



192 THE COUGH 

markedly from the acute form. But, as in the acute form, the 
constant symptom is the cough. This is persistent and obstinate, 
and usually much worse at night, sometimes occurring in par- 
oxysms which may suggest pertussis. 

Unlike the acute form, there is no elevation of the temperature 
and no malaise. Although the child affected may be and usually 
is thin, there seems to be but little affection of the general health. 
There is generally an abundant expectoration in the morning, 
and less during the day, of fetid pus or mucopus, and slight colds 
add materially to the amount expectorated. 

The course of the disease is quite indefinite, and there are 
seasons in which all the symptoms are decidedly relieved for 
a time, only to recur again. The time of least severity is with 
the advent of warm, dry weather. 

Inspection and percussion yield negative results; the ausculta- 
tory signs differ from the acute form in the milder degree of the 
signs present, and the fact that the chest is cleared after the 
coughing spell, until the mucus has had time to regather. Occa- 
sionally there is an absolute absence of any and all signs. 

In the matter of diagnosis it is not always easy to differentiate 
between chronic bronchitis and tuberculosis. One type of the 
latter is observed most frequently in children over five years of age, 
and has as its chief features successive attacks of transient spring 
or winter catarrhs, general muscular weakness, and persistent 
thinness of body, the persistence of which finally results in a 
decided pulmonary tuberculosis of the chronic type. The process 
is so long-drawn-out that the child is usually treated as a case of 
chronic bronchitis, and it is not until much damage has been done 
that the danger of the situation is realized. 

In every case which is at all suspicious a sputum examination 
should be made. This must be done by swabbing out the pharynx 
as low down as possible, for it is not sufficient to rely upon the 
child expectorating the material for examination. Even in the 
presence of a negative result every effort must be used to determine 
beyond all possibility of doubt the real nature of the disease, and 
this entails examination and reexamination of the child, and the 
exclusion of every other cause of wasting and failure to gain 
weight and strength. 



DISEASES WITH COUGH AS A PROMINENT SYMPTOM 1 93 

The persistent absence of fever at any time of the day is in 
favor of a diagnosis of chronic bronchitis. Chronic bronchitis 
is distinguished from pertussis by the presence of a somewhat 
typical expectoration and the history. Reflex coughs may at 
times offer considerable difficulty, and to detect their origin, 
every known cause of such must be considered. 

Bronchiectasis. — Dilatation of one or more of the bronchial 
tubes, with atrophic or hypertrophic changes in their walls, is 
occasionally seen in infancy and childhood. The symptoms are 
never pathognomonic. Cough is generally a marked symptom and 
is usually spasmodic or paroxysmal in character and associated 
with the expectoration of large quantities of fetid sputum. Gen- 
erally the paroxysms are most severe in the morning or when the 
position is decidedly and quickly changed. Sometimes the 
sputum is blood-streaked or there may be considerable hemor- 
rhage. 

Dyspnea usually precedes the coughing attack by some minutes, 
and the free expectoration generally results in marked relief of the 
dyspnea. The appetite is usually fickle, and the whole condition 
is one of gradually failing health and increasing cachexia. Sweat- 
ing at night is common, and the hectic fever associated with all of 
the other symptoms suggests a tubercular infection. Deformities 
of the chest may occur. 

The examination reveals diminished movement of the chest. 
Percussion shows dullness over the areas in which there is a large 
collection of mucus, but these areas are not constant, as a parox- 
ysm of coughing usually results in emptying them at least partiallv, 
upon which the dullness disappears or is much lessened. Aus- 
cultation reveals rales which are moist and of all varieties. 

Positive diagnosis is not usually possible, but the disease must 
be suspected when a child expectorates large quantities of fetid 
sputum, particularly in the morning or upon much exertion. In 
some rare instances, however, the sputum has little odor, and if 
the symptoms are at all marked, then it is extremely difficult to 
differentiate such cases at once from tuberculosis. Such a dis- 
tinction would necessitate sometimes repeated examinations of 
the sputum for the presence of the tubercle bacilli. 



M 



194 TH ^ COUGH 

In fact, the only way in which the disease can be positively 
recognized is by examination of the sputum. If repeated examina- 
tions fail in the detection of the tubercle bacilli, then we exclude 
tuberculosis ; if they fail to show the presence of histologic elements 
of lung tissue, then we exclude gangrene and abscess of the lung. 



EXAMINATION OF THE CHEST 

The examination of the chest in children is conducted by the 
same methods as are employed in adults, but there are certain 
peculiarities, particularly of auscultation and percussion, which 
must be remembered, or one will be led to wrong conclusions. 
These will be discussed later, under the respective headings. 

By such an examination it is possible to determine the activity 




Fig. 47.— Topographic areas of the anterior thorax. 



of the movements of the chest and also the physical condition of 
the parts under examination, but in young children especially 
too much emphasis must not be placed upon the value of such 
findings alone; their value is in their association with the general 
symptoms. 

195 



196 



EXAMINATION OF THE CHEST 



Inspection. — For the proper inspection of the chest the thorax 
must be bared, and it is best to have the child in a comfortable 
position, either on the bed or the mother's lap. Note -is then 
made of the shape and the size of the chest, the condition of the 
covering, and the character of the movements. 

The skin and subcutaneous tissues of the chest which con- 
stitute its covering should be supple and elastic. The color of 
the skin may be altered as part of a general alteration in color 
(see Cutaneous Surface). The subcutaneous tissue should be 




Fig. 48.— Showing the topographic areas of the hack. 



sufficiently developed to form an even covering, so that the bones 
are not prominent, an insufficient covering indicating general 
weakness or malnutrition of the child, and this in turn may be 
the result of disease. 

Shape of the Chest in Health. — This is almost impossible 
of such description that recognition would be easy; it is only by 
a method of repeated examinations of healthy chests that one is 
able to form a clear judgment of what is normal. 



SIZE — MOVEMENTS 



197 



Size of the Chest. — The size of the chest is determined by 
comparison with the measurements of other portions of the body. 
In the newly born the circumference of the chest should be below 
that of the head by one-half to one inch. By the end of the third 
year of life the chest measurement equals or slightly exceeds 
that of the head. 

Comparing it with the body length, in early infancy, the chest 
measurement at the line of the nipple exceeds half of the body 
length by from three to four inches ; at the seventh year they are 
about equal, and at the twelfth year the chest falls below the half 




Fig. 49. — The proper tape for the measurement of a child's chest. This can be readily 
made by sewing two ordinary tapes together. For use, the seam (A) is placed directly over 
the center of the spine, and by bringing the ends together in front, any difference in the 
measurement of the sides is at once noted. An addition of the measurements of the two sides 
gives the full chest measurement. 



length of the body by from one to two inches. Taking a large 
number of cases into consideration, the chest measurement at birth 
averages twelve to thirteen inches. At all ages the breadth of 
the shoulders should be one-fourth of the body length. 

Movements of the Chest. — Respiration consists in two events — 
inspiration, which is an active one, and expiration, which is pas- 
sive. Expiration is slightly longer than inspiration, and there 
is a slight pause between the two events. 

During inspiration the chest increases in vertical length and 



198 



EXAMINATION OF THE CHEST 



in circumference, and this is known as expansion. During 
expiration there is a decrease in circumference and vertical 
length, and this is known as contraction. The abdominal type 
of respiration prevails in infants, and costal breathing is the rule 
in children, and this is evidenced by the areas below the clavicles 
and the upper parts of the chest above the sternum expanding 
most perceptibly, the movements of the portions below being some- 
what limited. 

Changes in the Skin and Subcutaneous Tissues in Disease. — 
These parts may be the site of changes which are common to all 
portions of the skin and subcutaneous tissue, but there is one 




Fig. 50. — Measuring the chest. In this procedure it is best to use a tape similar to that shown 

in Fig. 49. 



condition occurring in the newly born which is peculiar to this 
situation. One frequently observes a condition of stagnation 
of secretion in the mammary glands of either male or female 
infants, occurring during the first few days of life and commonly 
resulting in considerable inflammation, which is known as mas- 
titis neonatorum. Such a condition must not be confounded 
with cold abscesses, which are covered with normal skin and are 
usually painless upon pressure. 

Changes in the Shape and Size in Disease. — These changes 
may be bilateral, unilateral, or local. Of the former, we observe : 



SHAPE IN DISEASE 



199 



Flat Chest. — The name describes the condition; the costal 
cartilages are straight, and as a result there is a lessened antero- 
posterior diameter, with a proportionately increased transverse 
diameter. This type of chest is generally associated with long 
neck and a general lankiness which are suggestive of a tuberculous 
tendency. An exaggerated form of flat chest is known as the 
pterygoid or alar chest, and its indications are similar to those 
of flat chest, only more so. 

Pigeon-breast. — In this chest the anteroposterior diameter 
is increased, while the transverse diameter is decreased, the 
sternum being very protuberant. Such a chest is indicative of 
some long-standing interference with perfect and free respiration, 

and is generally associated with 

enlarged tonsils and adenoid 
vegetations. It may be present 
to a degree in rachitis, but is not 
indicative of that disease. 

The Rachitic Chest.— The 
chest is shortened and with a 
more or less prominent sternum. 
The portion of the chest at the 
junction of the ribs and the cartil- 
ages is depressed, and this tends 
to force the lower part of the ster- 
num forward to a marked degree. 
The ends of the ribs are enlarged 

so that there is a distinct beading felt, and this is called the 
"rachitic rosary." The costal angle of the chest is generally 
quite acute. 

Funnel Chest. — There is a deep depression of the lower portion 
of the sternum. This is usually congenital and can often be 
observed in many members of a family. Its only importance 
is in its recognition as of no import. 

The Emphysematous Chest. — The anteroposterior diameter 
is increased, the sternum arched perceptibly, the ribs thickened 
and running horizontally outward, making a wide subcostal 
angle. It is, of course, indicative of enlargement of the lungs. 
An error that is frequently made is in mistaking a similar 




-Rachitic chest. 



200 



EXAMINATION OF THE CHEST 



condition which occurs in kyphosis, but in the latter there is no 
evidence of disease and the ribs are not thickened. 

Unilateral enlargement is usually most noticeable at the 
base. Generally it is the result of an accumulation of either 
gas or fluid in one pleural cavity, but it may be due to compensa- 





Fig. 52. Fig. 53. 

Figs. 52, 53. — Comparative chest contours. Heavy solid line, contour of normal chest. 
Fig. 52: Dotted line, showing the shape of the emphysematous chest. Fig. 53: Dotted line 
showing the contour of the rachitic chest. 



tion on account of disease of the opposite lung. If it is compen- 
satory, the affected lung is smaller than normal. When not 
due to compensation, the ribs are elevated, the side more rounded, 
and the interspaces usually obliterated. 

Unilateral Contraction. — In this the costal angles are sharper, 





Fig. 54- Fig. 55. 

Figs. 54,55. — Comparative chest contours. Heavy solid line, contour of normal chest. 
Fig. 54: Dotted line showing unilateral enlargement of the chest. Fig. 55: Dotted line 
showing the contour of unilateral contraction of the chest. 



the planes of the anterior and the posterior portions are depressed, 
the affected side looking flat before and behind. The ribs are 
closer than normal. Such a chest is usually the result of pleuritic 
adhesions, or may result from the collapse of a portion of the 
lung from a foreign body being lodged in one of the large bronchi. 



shape; in disease; 201 

If this is the case and the body has caused an abscess, the condi- 
tion is intensified. The shoulder then droops decidedly and there 
may be more or less spinal curvature, with the convexity toward 
the affected side. Great care must be exercised not to diagnose 
such a condition as scoliosis from some primary vertebral disease. 

Precordial Bulging. — This is somewhat characteristic of an 
enlargement of the heart. On the other hand, it may be due to a 
large pericardial effusion (which is a very rare happening in 
childhood), to pneumopericardium, to aneurism, or to tumor. 
Each would be differentiated by physical examination. 

Hypochondrium Bulging. — This is usually due to a large 
effusion into the pleura. If right-sided, it may also indicate 
some enlargement of the liver or the presence of a hepatic or 
subphrenic abscess. 

Local Depressions. — If these are situated just above or imme- 
diately below the clavicles, they are strongly indicative of tuber- 
culosis. In other situations they may be the result of muscular 
atrophies, of old fractures of the ribs, or of localized pleuritic 
adhesions. If at the lower end of the sternum, they are strongly 
indicative of interference with free respiration, and suggest the 
possibility of the cause being tonsillar hypertrophy or adenoid 
vegetation. 

Miscellaneous. — The ribs of the infant and young child are 
yielding and soft, and this is best tested by pressure over the 
sternum. While there is a yielding to pressure, there is at the 
same time a considerable degree of elasticity, and if this is mark- 
edly absent, it is indicative of some fault in the nutrition. Edema 
may be part of a general dropsy, or may be due to deep-seated 
abscess or empyema. 

Movements of the Chest in Disease. — The movements of 
the chest are uniformly and evenly increased in all acute affections 
of the lungs. It is the common accompaniment of elevation of 
temperature from any cause, and from the crowding of the chest 
which is noticeable in abdominal enlargement, the respirations 
are increased. Hysteria and many of the minor nervous states 
induce increased respiration. It is common to dyspnea from any 
cause. 

The influence of exercise, and even that amount of exertion 



202 EXAMINATION OF THE CHEST 

which is necessary to change the position, must be remembered 
as a cause of increased respiratory movement in children. The 
frequency is lessened when there is any pressure exerted upon 
the respiratory center. In some cases of collapse the respirations 
are decreased in frequency, as they are also in shock. Certain 
drugs, and especially in large doses, result in a marked decrease 
in frequency, and this is notably true of chloral and the opiates. 

What the ratio is between pulse and respiration has not been 
yet satisfactorily determined for children. In a large number of 
cases and by a large number of observers the respiration rate has 
been determined as : second year, respiration rate is 2 8 ; third and 
fourth years, about 25; sixth to tenth years, 20 to 25. 

Alterations in the Rhythm. — During infancy the respiration 
is not at all regular, but shallow breathing is followed by deeper, 





Fig. 56.— Counting the respirations. 

and so the two alternate. It is not uncommon to observe in a 
perfectly healthy infant a mild type of Cheyne-Stokes breathing. 

There may normally be a sinking of the points of attachment 
of the diaphragm on the lateral and the anterior walls of the 
chest, and this is particularly pronounced during crying. If it 
persists after the third year, it is indicative of an abnormal elas- 
ticity of the ribs, or of an interference with the free access of air 
into the lungs. 

Alterations in rhythm may be that the movements are slow 
and shallow, or deep, rapid, and shallow, or deep and irregular. 

Increased movement on one side indicates that the lung on 
that side is compensating for disease of the opposite lung. 



TYPES OF RESPIRATION 



203 



Unilateral diminution of movement indicates pain which may 
be due to pleurisy of that side, occlusion of important bronchi 
on that side of the chest, or that the air-space on the affected side 
is reduced to a considerable degree. 

Bach one of these must be recognized by the clinical signs. 



TYPES OF RESPIRATION 

It will be observed in any given case that one of two large 
types of respiration predominates. These types are the abdom- 
inal and the thoracic, the first of which is normal for the first 
three years of life, but which at that time rapidly gives way to 
the latter type. 

The Abdominal Type. — As has been stated, this is the normal 
type in early life. It may be exaggerated by any painful condi- 
tion in the chest or when there is a mechanical obstruction to 
free expansion. 

The Thoracic Type.— 
This becomes more and 
more prominent after the 
third year of life. When 
exaggerated, it indicates 
pain in the abdomen or 
an interference with the 
free use of the diaphragm 
and abdominal muscles. 
A very superficial thor- 
acic breathing is seen in 
nearly all cases of hys- 
teria. Pronounced costal 
breathing, associated with 

sighing or groaning and without the presence of a stenotic res- 
piratory murmur, suggests at once a commencing collapse of 
the heart, and it may be the very first indication which we have 
of that event. 

Cheyne-Stokes Breathing. — This is a type of breathing which 
in a mild form is not abnormal in infancy. The child ceases to 
breathe, then there follows a superficial and slow respiration which 




Fig- 57-— Palpation of the chest. 



204 



EXAMINATION OF THE CHEST 



increases both in depth and rapidity as successive respirations 
are observed, until there is an acme reached in which the breathing 
is both hurried and deep; then follows a gradual diminution in 

rate and depth until the 
/\/\/\/\/\/\/\/\ respiration again reaches 



AA/Vil/Wv^_^ 



Fig. 58.— Diagram illustrative of normal (upper 
line) and Cheyne-Stokes respiration (lower line). 



the period of arrest. This 
cycle may last for one-half 
minute or may be pro- 
longed for two minutes. 
It is most noticeable in 
tuberculous meningitis, and 
when it occurs in other dis- 



eases, is usually a sign of impending death. 

Sighing Respiration. — This is an occasional slow and deep 
inspiration followed by a somewhat rapid and audible expiration. 
It is observed during col- 
lapse and in meningitis; 
rarely in any other con- 
ditions. 

Stertorous Respira- 
tion. — Snoring is occa- 
sionally encountered in 
healthy children, but its 
occurrence should lead to 
an investigation of the 
nasopharynx, for most 
often it is due to adenoid 
vegetations. It is part of 
the condition of coma and 
is observed with marked 
frequency in concussion 
of the brain. 

Stridulous Respira- 
tion. — When a creaking, 
whistling, harsh, or 

screechy noise accompanies inspiration, it is known as stridulous 
breathing. It is always due to some laryngeal condition, and 
is of such import that it is discussed in detail under a separate- 
heading (see Laryngeal Stenosis). 




Fig- 59-— Illustrating the worthlessness of the 
ordinary phonendoscope in the examination of the 
chest of an infant. The broken lines indicate the 
spine. The solid line indicates the lower border of 
the left lung, showing that most of the lung is cov- 
ered by the instrument. 



TYPES OF RESPIRATION 



205 



Palpation. — When palpation is performed, the hands should be 
previously warmed and the part palpated should be bared. By 
this method there is a confirmation of the results of observation 
or inspection, the vocal fremitus is determined, the consistency 
of parts ascertained, and the presence of fluctuation detected. 

Vocal Fremitus. — During early infancy it is only possible to 
obtain vocal fremitus by the cry. It is increased when consoli- 
dation is present, so that it is noted in pneumonia and in tubercu- 
losis when the cavity has thickened 
walls. It is diminished when there 
is anything intervening which di- 
minishes the normal conductivity 
of the vibrations, so that diminu- 
tion is most often observed when 
there is a cavity filled with fluid 
and in thickened pleura. It may 
be absent when a bronchus is com- 
pletely occluded, when there is much 
accumulation of fluid or of air in 
the pleura, and in some cases when 
the thickening of the pleura is 
marked. 

Bronchial fremitus is when vibra- 
tions are transmitted by the pas- 
sage of air through the fluid or 
mucus which may be contained in 
the bronchial tubes, and these are 
felt during inspiration. They are 
common to all cases of bronchitis, 
being felt all over the chest, and in 
asthma they are also noted. The 

distinctness is sometimes so marked in bronchitis that it is the 
one thing which appeals to the parent, and they usually designate 
them as "the rattles." 

Friction fremitus is felt in inspiration and increased bv deep 
breathing. It is indicative of pleuritic inflammation. 

Percussion. — Many times the chests of young children arc 
asymmetrical, and if percussion is performed over the side with 




Fig. 60. — Position for examination 
of back of chest. The child can be 
perfectly controlled by the nurse in this 
position. 



206 



EXAMINATION OF THE CHEST 



the most marked convexity, a duller sound will be obtained than 
upon the opposite side. If the position of the child is faulty 
(bent toward one side, instead of lying, sitting, or being held 
in a straight position), one side is much duller than the other. 
This applies with equal force to the examination of the chests of 
children with spinal curvatures. If the muscles of the chest are 
strongly contracted from any cause, and this is generally the result 
of pain, or may be because the child insists upon keeping the arm 
raised over the head, there is dullness which is noticeable over 
the contracted muscle. 




Fig. 61. — Illustrating an incorrect method of auscultation of an infant's chest. The tubes 
of the stethoscope are twisted and the position of the examiner favors congestion of the audi- 
tory apparatus, thereby interfering with perfect appreciation of sound. 



If the child is crying at the time of the examination, percussion 
must be performed with short, quick strokes until the time of 
deep inspiration, otherwise dullness is the only thing obtained. 
Owing to the elasticity of the child's lungs, percussion should be 
performed with very light strokes. Owing to the natural rebellion 
of the child, percussion should be delayed as late in the examina- 
tion as possible. 

Auscultation. — Whenever possible, the back of the chest 
should be the part examined with the stethoscope. When the 



TYPES OF RESPIRATION 207 

ear is used in auscultation, one is never sure of the exact spot 
examined, as the child usually is making efforts to avoid exami- 
nation. Then, again, the surface to be examined is so propor- 
tionately small and the movements of the chest so rapid that the 
use of some instrument is really necessary. 

If the child cries, it is a good thing, for it is a valuable adjunct 
to the detection of abnormalities, revealing the vocal fremitus 




Fig. 62. — One correct method of auscultation of the anterior chest of an infant. 

and bronchophonia, in addition to finer rales and respiratory 
murmurs, which otherwise would go undetected. Puerile breath- 
ing is intensified respiration, but with no alteration in quality 
or pitch, and this is normal in infants. In children over three 
years of age it is abnormal, and occurs usually over a healthy 
lung only when there is disease of the opposite lung which shifts 
the burden of respiration to the unaffected lung. 



DYSPNEA 

Dyspnea is really difficult or labored breathing, and there is 
usually a sense of breathlessness of which the older child may 
complain. The respirations are little, if any, increased in fre- 
quency, but there is a marked increase in their depth. Occurring 
during the course of a disease or condition which hastens the 
frequency of respiration, naturally there is hurried breathing, 
but this is due to the disease and not simply to the sense of air- 
hunger. There is more or less cyanosis, and the expression is 
usually an anxious one. If at all marked, then the lips are 
parted, the pupils dilated, the nostrils widely dilated, and the 
skin is cold and wet. The sensation is produced by inefficient 
■exchange of oxygen and carbon dioxid in the tissues, and partic- 
ularly by a diminution in the supply of the former. 

In a general way, the causes of dyspnea are: any obstructive 
condition of the air-passages resulting in a diminution in the 
free access of air to the lungs, conditions which hinder free 
chest expansion (pain is the most common in children), dimin- 
ished hemoglobin in the blood, and cardiac conditions favoring 
pulmonary stasis. 

Dyspnea upon exertion is usually due to marked anemic 
conditions, cardiac disease, bronchitis, and pulmonary emphy- 
sema. 

When anemia is sufficient to give evidences of dyspnea, the 
symptoms of the impoverished blood condition are so marked 
that one cannot fail in its recognition. 

Chronic valvular disease is of two marked stages in childhood : 
the first, when compensation is good; the second, when it is not. 
The first stage is the time that we ought to recognize the disease, 
for this period may be prolonged indefinitely. Most often its only 
evidence, subjectively, is dyspnea. What few other symptoms 
are present have little positive diagnostic value. The slightest 

208 



ASTHMA 209 

evidence of dyspnea in an apparently healthy child should at 
once suggest the possibility of its cardiac origin. 

In young infants dyspnea is very real in many cases of bron- 
chitis, bronchopneumonia, and the laryngeal affections. 

It must not be forgotten that severe dyspnea may be the first 
symptom to suggest the cause of an indeterminate and obscure 
severe illness which can be explained upon no reasonable basis 
until an examination is made of the throat and a retropharyngeal 
lymphadenitis discovered. 

Paroxysmal Dyspnea. — This must not be confounded with 
dyspnea which occurs upon exertion only, for it occurs irrespective 
of that. Such attacks are suggestive of either laryngeal stenosis 
or chronic valvular disease of the heart. 

Inspiratory Dyspnea. — When the dyspnea is marked on 
inspiration, but the expiration is comparatively easy, and such 
an attack comes on suddenly, it is strongly indicative of a foreign 
body in either the larynx or the trachea. Occurring suddenly 
and persisting for a few minutes and recurring occasionally, it 
may be due to a spasmodic condition, laryngismus stridulus, 
which is indicative of malnutrition. 

Asthma. — As this is a disease which has as its chief character- 
istic attacks of severe spasmodic dyspnea, it will be considered 
at this time. It is a disease which attacks the child at any age 
and the infant is not exempt. Like many other neuroses of 
uncertain origin, the assigned causes of asthma are multiple. In 
many instances the term is misunderstood and is loosely applied 
to any form of dyspnea, irrespective of the cause. 

Most frequently the symptoms appear during the night-time 
and with suddenness. They may then last for hours or persist 
for several days or even weeks. If the persistence of the course 
is a notable feature, there are exacerbations and remissions which 
follow one another for that time. The usual course is a nightly 
recurrence, so that the child becomes quite exhausted. 

Sometimes the development of the attack is during the course 
of bronchitis. But whatever its development, there is one con- 
stant characteristic of the attacks, and that is the dyspnea. In the 
dyspnea the obstruction occurs in expiration ; there is diminished 
respiratory movement, the expiration is prolonged and attended 
14 



2IO DYSPNEA 

with a wheezing sound, and the inspiration is short and catchy. 
The sense of air-hunger may be extreme and the face has an anx- 
ious expression, is pale, or may be cyanotic, and the child holds 
himself rigid in the sitting position. In infants there may be 
an elevation of the temperature, but in older children it is com- 
monly slightly subnormal. 

The character of the chest sounds as revealed by auscultation 
are not mistakable. They consist principally of sibilant or 
sonorous rales, more or less musical, and of much variety as regards 
pitch and intensity, and are heard all over the chest during both 
inspiration and expiration. In infants moist rales may be 
present also. Sputum examination shows the presence of Cursch- 
mann's spirals, Charcot-Leyden crystals, eosinophiles, and small 
round bodies like sago grains. 

The diagnosis is made from all other forms of dyspnea by the 
suddenness of the onset, the abrupt termination, the prolonged 
expiration, the characteristic chest sounds, the tendency to 
recurrence, and the examination of the sputum. The dyspnea 
differs from the dyspnea caused by croup, for the soft parts of 
the neck and the chest do not recede during inspiration, but 
instead there is evidence of distention of the lungs, which is 
characterized by the sinking of the diaphragm and a diminution 
of the cardiac dullness. If the attack develops during the course 
of bronchitis in a young infant, the diagnosis is made more difficult. 
Such cases markedly simulate bronchopneumonia. The sudden- 
ness of the appearance of the dyspnea without signs in the chest 
which would account for it, the absence of small rales especially 
and of fever at times, helps in the exclusion. 

Hay-fever. — This is a neurosis which is closely related to 
asthma, and by some is classed as a form of asthma. I believe 
that the evidences of the disease are marked enough to allow of 
its clear distinction as a separate disease In the United States 
the disease is most prevalent from August to November. It is 
not a common occurrence before the tenth year of life and is 
rare before the sixth year. 

The onset usually occurs with gradually prolonged and severe 
sneezing and a sensation as though the nose was being tickled. 
The mucous membrane of the nose, throat, and eyes becomes 



PULMONARY EMPHYSEMA 211 

more or less acutely inflamed and there is an abundant discharge. 
More or less severe pain is complained of and is referred to the 
head, face, and eyes. The general symptoms are those of a mild 
prostration, there are some slight alterations in the temperature, 
pulse, and respiration, with usually the final occurrence of an 
acute emphysema. After several successive attacks the child 
is usually the subject of asthma, which not infrequently persists 
throughout the winter months. 

Pulmonary Emphysema. — In this condition there is a marked 
shortness of breath upon the slightest exertion and cyanosis is 
very easily produced. It is markedly favored during early life 
on account of the proportionately greater amount of connective 
tissue which is present at that time, and for that reason it is not 
unusual to find it frequently accompanying the diseases of the 
lungs in infancy and early childhood, and particularly when the 
condition is acute. 

There are two groups of cases: those which are the result of 
the effort of the lung to compensate, on account of disease, and 
those cases which are dependent upon obstruction to expiration. 

When the condition occurs during the course of some acute 
disease, there is an exaggerated resonance upon percussion. Out- 
side of that there are no symptoms which are peculiar. Under 
any condition, when pulmonary emphysema occurs, there is, 
upon percussion, an exaggerated resonance and the areas of 
cardiac and hepatic dullness are sometimes markedly diminished. 
This is because the lung encroaches more upon these areas than 
it does when conditions are normal. 

Auscultation is variable, but in most instances there is a some- 
what prolonged expiratory murmur which has a low pitch. There 
are, of course, the associated signs of the primary disease. With 
the encroachment of the lung upon the cardiac area, there is 
naturally more or less obscurity of the heart-sounds. 

Usually after the termination of the original disease there is a 
subsidence of the pulmonary emphysema, and although it is 
never entirely cleared up, the subsidence and improvement are 
marked in a few weeks. 



212 DYSPNEA 

LOBAR PNEUMONIA 

This disease, which is an inflammation of the lungs due in the 
majority of instances to the pneumococcus, affects the child at 
any age, and may even be congenital, the infection occurring 
through the placenta of the mother. The disease always has an 
acute course with a sudden onset, with high temperature and rapid 
hepatization, and when typical, with a crisis on the sixth to the 
eighth day. Hepatization may affect the whole of a lobe of the 
lung or almost all of it. 

There are cases which run a very much shorter course in which 
every symptom is modified or is very mild, so that the whole 
duration of the disease may not exceed three or four days at most. 
The only way in which the mild and atypical types differ from the 
typical is by the variations being indicated by the different 
character of the concomitant symptoms and by the course of the 
disease. 

One anomalous type which is not at all uncommon is that in 
which all the symptoms are marked and typical for the first 
seventy- two hours or so, and then there occurs a sudden and 
complete clearing up of all signs of the disease, the affection not 
going beyond the stage of congestion. 

The onset is uniformly sudden, and in children over six or seven 
years of age it is accompanied with chills, as in adults. In younger 
children there is some condition present which approximates that 
of the chill, so that we observe frequently a convulsion, or coldness 
of the extremities, and cyanosis which is most marked about the 
lips. 

Irrespective of the age, one characteristic of the disease is its 
rapid onset with high temperature (103 to 107 F.), and this 
onset is not preceded by bronchitis or other disease essentially, 
but is independent of all such conditions. Vomiting is a very 
common occurrence at the onset, and when the weather is warm, 
diarrhea is usually added. 

If the child be old enough to complain intelligently, headache 
and muscular pains are fairly constant features at the onset, and 
upon the first or second day of the disease pain in the side, which 
is increased by the act of coughing or of deep inspiration, is com- 
plained of. 



LOBAR PNEUMONIA 



213 



If the child be under the age of five, then the pain in the side is 
usually not evident, but instead it is referred to the loin, to the 
epigastrium, or to any situation to which the intercostal nerves 
are distributed. Such pain is generally moderate and of short 
duration, but may at times be so intense as to suggest conditions 
outside of the chest as the cause. There is one feature about such 
pain — that it is never exactly located. 

In infancy, if one observed evidences of abdominal pain with 
vomiting, the possibility of lobar pneumonia should at least be 
thought of, for at this age gastric disturbances are usually not 
accompanied early by abdominal pain. It is a safe rule for the 
diagnosis of the disease, in any event, to suspect its occurrence 
whenever there is a rapid rise of temperature associated with 



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Fig. 63.— Chart of the temperature ( — ) and respirations ( ) in lobar pneumonia. Child 

one year old. 



markedly increased respirations. And if a short dry cough is 
present, and also vomiting, coated tongue, etc., the diagnosis is 
strengthened. 

While increased respirations occur as a natural consequence of a 
rise in the temperature, dependence may be placed upon its value 
only as there is a marked increase. It is out of all proportion to 
the increase in the pulse-rate, which normally is about one to 
four, but which in this disease may be one to two. The respira- 
tions are usually jerky (if pain is caused by breathing), and are 
accompanied by a short moan or a short sighing effort, which is 
characteristic only if associated with the other symptoms (as it 
may be observed in dyspnea from other causes). 



214 



DYSPNEA 



Prostration is generally an early and very noticeable feature, as 
is evidenced by the child giving up easily and becoming ex- 
hausted. The pulse is in the beginning full and frequent, but 
soon becomes weak, small, and compressible, and sometimes very 
irregular. Even upon the very first day of the disease the symp- 
toms are sometimes such that the diagnosis can be made without 
waiting for definite physical signs. 

In considering the value of Weill's sign (that there is a lack of 
expansion in the subclavicular region of the affected side, irre- 
spective of the situation of 

Lobar Pneumonia (I). the lesion), I have found that 

it is present in a very large 
proportion of the cases at 
some time, and is an early sign 
in a majority of all cases, so 
that it allows of an early re- 
cognition of the conditions 
present. 

It is usually not until the 
second day of the illness that 
cough is present, and then 
it continues throughout the 
course of the disease. It is 
short, dry, and restricted until 
the time just before the crisis, 
and in children who are old 
enough to expectorate there 
is usually then an abundant 
expectoration of brownish-red 
or yellowish secretion. 
After the first rise, which is characteristically abrupt, the tem- 
perature becomes more or less remissive, with daily fluctuations of 
one to two degrees, until the time of the crisis, when there is an 
abrupt fall. The urine is naturally scanty and high-colored, and 
may have traces of albumin through it. Cerebral symptoms may 
predominate for a time, so that we may observe those which are 
suggestive of the typhoid state or those which are more sug- 
gestive of meningitis. 




Fig. 64. — Part (or all) of one lobe is con- 
gested (HUH ) ; slight dullness may be detected 
over this area, or there may be only diminished 
resonance. Crepitant rales and feeble respira- 
tory murmur exist over affected area. All 
healthy lung is hyperresonant. 



LOBAR PNEUMONIA 



215 



The Physical Examination. — One must not expect to find 
signs exactly similar to those in adults. If the peculiarities of 
the child's chest are not taken into account, the examination 
will prove misleading instead of conclusive. 

The earliest percussion signs which we would look for are those 
which are due to the acute congestion. In consequence of this 
condition, less air gets into the affected area and more is forced 
into the healthy portions of the lungs, so that there is usually, 
over the affected area, a diminished resonance with an exaggerated 
resonance elsewhere. This sign, however, is not in any way 
conclusive. Percussion may 

r ... ^*. ,, Lobar Pneumonia (II). 

even fail to outline the 
affected area, either because 
the area is limited in its ex- 
tent, is covered with healthy 
lung, is deep-seated, or be- 
cause a gas-distended stomach 
or intestine interferes with the 
examination. 

At the onset, auscultation, 
which is valuable in adults, is 
valueless in children, because 
they will not breathe deeply 
on account of the pain. 
Usually the first auscultatory 
signs are a feeble respiratory 
murmur over the affected 
part, with rather nigh pitch, 
while healthy portions may 

show exaggerated sounds. The latter may be mistaken for 
bronchial breathing, but it differs in no way from normal breath- 
ing, except in its intensity, and is heard upon inspiration only. 

Bronchial breathing is still higher in pitch, and is heard with 
nearly uniform intensity upon expiration as well as inspiration. 
When consolidation occurs, percussion exhibits marked dullness 
over the affected area, with exaggerated resonance elsewhere. Aus- 
cultation shows bronchial breathing and bronchial voice over the 
affected area, and this is clearly and sharply defined. Rales 




Fig. 55. — congestion increased ana in 
center of affected area, pure bronchial breath- 
ing may exist ; dullness still remains slight (in 
solid black). 



2l6 



DYSPNKA 



may be observed or there may be pleuritic friction sounds 
present. 

With the advent of resolution all the signs of consolidation 
gradually lessen, and as far as percussion is concerned, the most 
persistent signs are slight dullness or diminished resonance. The 
breathing becomes bronchovesicular, with the latter element 
predominating. Moist rales of all varieties are heard. There 
may be persistence of dry friction sounds, or of respiratory mur- 
mur, which is more feeble than normal and slightly higher in 

pitch (accompanied with slight 
lobar Pneumonia (in). percussion dullness or dimin- 

ished resonance). 

The diagnosis is usually not 
difficult, for the sudden onset 
with the characteristically 
high temperature, disturbed 
pulse-respiration rate, cough, 
expiratory sigh or moan, and 
the physical signs are suffi- 
ciently marked not to mislead. 
The sudden onset with 
vomiting might lead to the 
suspicion of scarlet fever or 
tonsillitis as the cause. Scar- 
let fever would be distin- 
guished by the appearance of 
the characteristic eruption on 
the day succeeding the abrupt 
onset, or, in those cases in 
which there is little or no eruption, the history of exposure and 
the presence of sore throat would suggest its possibility, and 
later, when the physical signs of pneumonia should appear, the 
evidence would be conclusive. 

An acute tonsillitis is much harder to differentiate unless there 
is a clear history of such attacks occurring previously and the 
local signs are marked, for it is upon these latter that we depend 
for an early diagnosis. 

During the first day, in infants, an acute gastro-enteritis may 




Fig. 66.— Consolidation (solid black) com- 
plete in the second stage with dullness marked ; 
congestion more wide-spread ; some rales or 
friction sounds. 



LOBAR PNEUMONIA 217 

be suspected, for vomiting and diarrhea are so common at this 
time ; but when pneumonia is the cause, the temperature and the 
prostration are both out of all proportion to the mildness of the 
intestinal condition. 

If during the first days of the disease a dull percussion sound 
is detected over the inferior lobe of the lung, there may be a 
question as to its being due to pleuritic exudate. Moderate 
exudate may give dullness, but associated with it there is a 
weakened vesicular breathing and not bronchial respiration, as 
in pneumonia. 

If herpes are present on the lips or nose, then pleurisy may be 
almost conclusively excluded, as herpes is so rare in pleurisy and 
so common in pneumonia. Vocal fremitus, which is so valuable 
in adults in differentiation, is of no service in this instance in the 
child. Dependence must be placed upon the character of the 
fever, the course of the disease, and the physical signs. 

In lobar pneumonia the fever is characteristically high (higher 
than in most other diseases), while in pleurisy there is not so 
sudden an invasion, but the temperature takes considerable time 
to climb to any very marked height. In pneumonia there is an 
end by crisis in a few days ; in pleurisy there is lysis and persistence 
for three or more weeks usually. The physical signs in pneumonia 
correspond to the affected lobe and appear almost at once over 
the whole surface, while in pleurisy, dullness appears in the lower 
portion of the lung behind and then slowly increases upward 
before it is detected anteriorly, the upper border anteriorly always 
being lower than that posteriorly. 

If, even under such examination, the cause of the symptoms re- 
mains in doubt, an exploratory puncture may be made. 

It is a safe rule, and in fact a very necessary one, to suspect the 
lungs whenever there is a rapid rise of temperature with much in- 
creased rate of respiration. This would lead to examination and 
reexamination of the chest until the diagnosis of the disease pres- 
ent was sufficiently clear. And a hasty examination of the more 
prominent parts of the child's chest is not sufficient unless the dis- 
ease is very typical, for pneumonia in children with obscure 
symptoms has a remarkable tendency to locate in the more ob- 



"2 1 8 DYSPNEA 

scure portions of the chest (as high in the axilla or just beneath 
the clavicles). 

Occasionally, at the onset of a lobar pneumonia, the physical 
signs are not in sufficient evidence to allow of a diagnosis, and the 
constitutional symptoms which may be present (vomiting, possi- 
bly convulsions, delirium, stupor, and even opisthotonos) suggest 
meningitis. In some of these cases it seems as though the symp- 
toms were designedly deceiving. The symptoms are so suggestive 
of meningitis from the very start that some authors class this form 
as a cerebral pneumonia. 

The cerebral symptoms are apt to differ to a considerable ex- 
tent according to the period of life — infancy or later childhood. 
In infancy there is a sudden onset, usually with vomiting and 
quickly followed by convulsions and semi-consciousness. If the 
convulsions are not repeated, the semi-consciousness is of short 
duration, and the disease then in no way differs from its usual 
course; but if repeated convulsions occur, then the child is for 
days in a stupor. Other cerebral symptoms then appear under 
the influence of passive hyperemia of the brain, so that one may 
observe rigid neck muscles, dilated pupils, possibly strabismus, or 
temporary facial paresis. 

In the form as it attacks older children convulsions are absent 
and the somnolent and indifferent condition of the child is more 
suggestive of the typhoid state than of meningitis. The tongue 
may be dry and coated. Delirium is usually present at night and 
the urine and feces may be voided involuntarily. Added to this, 
there are occasionally rigidity of the neck muscles, a general hyper- 
esthesia, and constipation, possibly with sunken abdomen. 

In all such cases the character of the fever is important ; that 
is, in lobar pneumonia there is a constantly high temperature, so 
that in the presence of a morning and an evening temperature of 
104 which has developed suddenly, meningitis would practically 
be excluded. Such a sudden development with convulsions is 
peculiar to but one form of meningitis, the purulent, and there is 
usually abundant evidence as to the cause for its development. 

In pneumonia if the convulsions subside even for a few hours the 
mind of the child clears quite rapidly, which is not true of men- 
ingitis. In pneumonia also the pulse is not slow and intermittent 



BRONCHOPNEUMONIA 219 

at first, nor is the respiration somewhat slow and irregular, as so 
often occurs in meningitis. Meningitis exhibits a more profound 
stupor and a steady increase in the nervous symptoms for three 
or four days, while in pneumonia they may be very marked dur- 
ing the first twenty-four hours, but generally quickly subside as 
the pneumonia develops. 

A safe guide to the correct diagnosis is this : without paying too 
much regard to the variety and severity of the symptoms, if ner- 
vous symptoms are present from the onset and are marked, men- 
ingitis may reasonably be excluded. If they are present at the 
onset in a mild form, but show a steady increase in severity, or if 
not present at the onset but appearing later and steadily increas- 
ing, then meningitis is to be suspected and not lobar pneumonia. 
This reasoning holds true even in the presence of pneumonia, dur- 
ing the course of which meningitis is not an unusual complication. 

In the form attacking older children, in which the symptoms at 
first are those of the typhoid state, the history of an initial chill 
would almost positively exclude typhoid fever, and the early oc- 
currence of the somnolence and typhoid symptoms so quickly 
after the first signs of illness would at least be very suspicious of 
pneumonia and decidedly against a diagnosis of typhoid. At 
most, one could not possibly remain long in doubt, for the tardy 
physical signs would eventually show themselves. The diagnosis 
from bronchopneumonia is considered under that disease (see 
page 224). 

BRONCHOPNEUMONIA 

This disease is essentially one of infancy and early childhood, 
being quite uncommon after the seventh year of life. In a great 
many of its aspects it is impossible to decide whether this affection 
should be classed as a distinct disease or not. It seems to be a 
combination of two or more diseases at times. Clinically, there 
is a decided element of mixed infection, with a complexity of 
symptoms which constantly change as one elementary lesion or 
another finds prominence. In its multiplicity of forms there is 
one common lesion, however — capillary bronchitis. 

If all its varied phases were to be considered separately, there 
would be created an indefinite number of forms of the disease. 



220 DYSPNEA 

which would be confusing. Capillary bronchitis, while it may 
give no evidence of a pneumonic process during life, should be 
classed as a form of bronchopneumonia, because while recogni- 
tion of such a process (pneumonic) is not detected during life, it 
invariably is at autopsy. One of the chief differences between 
this disease and lobar pneumonia is that the former is invariably 
preceded or accompanied by symptoms of catarrh of the small 
bronchi. 

There are many predisposing causes of the disease, the chief 
ones being the age of the child (infancy) and the state of the nu- 
trition (malnutrition). Naturally any disordered condition of 
the nutrition of a chronic nature is a factor in the etiology; as 
marasmus, rachitis, syphilis, etc. Other predisposing causes are 
poor hygienic surroundings, changeable climate, the cold season, 
the aspiration of foreign substances, the infectious diseases, and so 
forth. With one or more of these present, it means that the excit- 
ing factor (infectious organisms commonly present in the nose, 
mouth, or throat) need only be slight to start the process. Of all 
the- single conditions or diseases which predispose to the disease, 
bronchitis leads. 

As has been stated, the one common lesion is capillary bronchi- 
tis, and the inflammation involves the whole thickness of the tubu- 
lar walls and invades the surrounding tissue. By spreading to 
the alveoli, there are formed small inflammatory foci, and as the 
disease advances several of the formed areas of hepatization may 
coalesce, forming larger foci. Now, clinically such a process gives 
evidence of itself at first by symptoms which indicate a capillary 
bronchitis with fever. 

The mode of onset is as varied as most of the other features of 
the disease, and may be gradual or very sudden ; the temperature 
may be high or remain only slightly elevated throughout the 
whole course of the disease ; the cough may also be very hard or 
very slight, and so one might go on and enumerate nearly every 
symptom. The only certain thing about the disease is its remark- 
able uncertainty. 

The commonest form of development is that which comes dur- 
ing an attack of bronchitis, when it is noticed that all the symp- 
toms or most of them are intensified. This intensification is par- 



BRONCHOPNEUMONIA 



221 



Bronchopneumonia (I). 



ticularly observed in the temperature, which may exhibit an eleva- 
tion to 103 to 106 F. While the temperature is high, it is sub- 
ject to considerable fluctuation, and sometimes shows a daily va- 
riation of from four to five degrees Fahrenheit. In rare instances 
it may assume a nearly continuous type. 

Low temperatures are very apt to be the rule in delicate chil- 
dren, and this is particularly true of infants suffering from maras- 
mus. Dyspnea is very real and is an early and constant symptom, 
being easily induced by the acts of crying, nursing, coughing, or, 
in fact, any excitement. As- 
sociated with the early occur- 
rence of dyspnea there is the 
presence of more or less abund- 
ant small rales, particularly in 
the lower portion, behind. 

Cough is a much more con- 
stant feature than it is in lobar 
pneumonia, and at first it is 
dry and hacking, but may 
have a whistling character, 
terminating with a short, 
sharp cry, indicating pain. 
The persistence of the cough 
materially disturbs the little 
one's rest, adds to the general 
discomfort, and may excite 
vomiting. No expectoration 
is present in the very young. 

The respirations are always 
much increased, and, as a rule, 

are between fifty and one hundred to the minute, and associated 
with dilatation of the nostrils and sinking in of the soft portions 
of the chest, as is observed in severe dyspneas. 

The Physical Examination. — It is somewhat characteristic of 
the disease that it exhibits appearances of hepatization first in the 
back, but on both sides of the spine, and consonant rales may be 
heard there (if the disease is diffuse) for a considerable period with- 
out any sign of distinct dullness. In fact, for several days per- 




Fig. 67.— Coarse sonorous rales (O) at first 
are detected over both lungs or over a limited 
area. Feeble breathing over limited area with 
addition of fine sibilant (00) rales indicates 
commencement of first stage. 



222 



DYSPNEA 



cussion may reveal nothing but hyperresonance. The amount of 
percussion dullness is exceedingly meager in proportion to the ex- 
tent of the consolidation, and if much dependence is placed upon it 
as an indicator, it will prove misleading. Frequently it is not ob- 
tained until the third or fourth day of the disease. It cannot be 
too frequently reiterated, or too forcibly impressed, that broncho- 
pneumonia may exist in a child and run its full course without the 
signs of consolidation having been present at any time during the 
disease. This is true even of some of the cases in which the dis- 
ease runs a protracted course. 

Bronchopneumonia (II). The result is that auscultation 

is of much greater value in 
the recognition of the condi- 
tion. 

There is feeble breathing at 
first over the affected area on 
account of the congestion. 
With this are found coarse 
sonorous and also fine sibilant 
rales, which are soon replaced 
by the very fine moist rales. 
These are somewhat definitely 
located in the lower lobes, 
posteriorly. 

The respiratory murmur is 
enfeebled and assumes a higher 
pitch. Everywhere else in the 
chest (except lower portion, 
behind) there may be found 
coarse rales which have per- 
sisted and are due to bronchitis of the larger tubes. In many 
instances these are all the signs which are obtainable through- 
out the disease. 

The next change is generally that the fine moist rales are heard 
over a much enlarged area and are more strictly localized at some 
one point, and this is usually over one lower lobe, posteriorly, and 
close to the vertebral column. At this place the rales are found to. 
be louder, higher in pitch, and apparently more superficial. Over 




Fig. 68. — Coarse rales increase in extent ; 
fine moist rales are heard over enlarged area 
and are more localized, more superficial, 
louder, and higher in pitch. May be partial 
consolidation (=— )■ 



BRONCHOPNEUMONIA 



223 



Bronchopneumonia (III). 



such an area there is bronchovesicular and enfeebled respiration, 
and as the consolidation becomes more evident, bronchial breath- 
ing becomes more and more pronounced. 

The areas of consolidation are not, as a rule, sharply defined, and 
are at first small, with an extension until nearly all of one or both 
lungs, posteriorly, give signs of involvement. Bronchial breath- 
ing is pure over the center of the consolidated area, but there are 
rales at the edges. Friction sounds are rare. In the later stages 
of the disease the evidences of 
the bronchitis persist often 
over the entire chest, but 
most markedly or entirely 
behind, the coarse and finer 
rales intermingling. 

Convalescence is indicated 
by the gradual disappearance 
of the signs of consolidation 
and the persistence of rales of 
all kinds and friction sounds 
perhaps for two or more 
weeks. 

Even with its variable 
symptoms the diagnosis of 
bronchopneumonia is presum- 
ably made if, in an infant, 
we observed a high temper- 
ature with marked daily 
fluctuations, associated with 
much increased respiration, 

cough, and dyspnea, and positive signs of other disease being 
absent. 

From bronchitis it is distinguished by the more marked intensity 
of all the symptoms, except the cough (which is usually worse in 
bronchitis), so that during the course of bronchitis if there is an 
intensification of symptoms, we suspect the development of bron- 
chopneumonia. 

Of much importance in the distinction is the presence of real 
dyspnea, which is not present in bronchitis. Subcrepitant rales 




Fig. 69.— The area of partial consolidation 
increases and other small areas are found scat- 
tered over both sides. There may be complete 
consolidation ( ||§ ) near the center of these 
areas. 



224 



DYSPNEA 



which are heard at the base of the lung and increased percussion 
resonance are indicative of bronchopneumonia . If instead of 
being diffuse, as they are in bronchitis, the rales show a tendency 
to limitation at certain points, the diagnosis of bronchopneumonia 
is probable. 

The distinction from lobar pneumonia is usually easy, for in that 
disease the inflammation at once occupies the lung tissue without 
a preceding bronchitis, and from the very start a whole or almost a 
whole of one lobe is affected. It occurs in later childhood usually 

and in previously healthy 
children. The onset is with 
well-defined symptoms, sud- 
denly developed and running 
a typical course. Broncho- 
pneumonia is mostly bilateral, 
and the favorite situation is 
the lower portions of the lung, 
behind, while lobar pneumonia 
is unilateral and shows no 
preference for the lower part 
of the chest, affecting the 
upper portions quite fre- 
quently. 

In lobar pneumonia the 
temperature at once is high, 
and with considerable oscilla- 
tions maintains the same level 
for several days, ending with 
a crisis, but in bronchopneu- 
monia the temperature is not 
so suddenly developed, nor does it rise to such a height, and 
when high remains so only for a short time (a few hours), exhibit- 
ing considerable variations daily, which may amount to four or five 
degrees Fahrenheit. The termination is by lysis, which lasts from 
three to seven days. 

When the course of a bronchopneumonia is protracted for sev- 
eral weeks, the question at once arises whether there is a tuberculous 
process present or not. This is especially the case if there have 




Fig. 70.— During resolution, the areas of 
complete consolidation disappear; the partially 
consolidated areas decrease and are scattered 
with gradually disappearing coarse and fine 
rales over both sides. 



BRONCHOPNEUMONIA 



225 



been the formation of bronchiectasiae and upon examination large, 
consonant rales are observed with cavernous respiration. To cor- 
rectly differentiate these two diseases advantage must be taken of 
every possible facility to determine the family history and every 
other factor which might prove of value. 

Physical signs are not sufficient for the diagnosis, for in both 
conditions they may be similar ; and in many instances the etiology 
seems to be the same. The onset of tuberculosis is usually gradual ; 
it may have been apparently sudden, but a careful consideration 
of the history will generally show beyond all doubt that for 
weeks before there have been symptoms present which would in- 
dicate a tuberculous infection, but these have been overlooked at 
the time. 



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Fig. 71.— Chart of the temperature ( ) and respirations ( ) in bronchopneumonia. 

Child one year old. 



When the development is sudden (apparently) there is nothing 
in the physical examination or in the constitutional svmptoms 
which will aid in the differentiation except that at times there is a 
loss of flesh which is disproportionate to the severity of the svmp- 
toms. No positive diagnosis is possible until the time of expected 
resolution in bronchopneumonia, and then instead of its occurrence 
we are sometimes confronted with a persistence of svmptoms which 
at once suggests the possibility of tuberculosis. No reliance can 
be placed upon the character of the temperature. Examination 
of the sputum is of little value, for in children under six or seven it 
is almost impossible to obtain the proper material for an examina- 
tion. Wasting which is out of proportion to the severity of the 
15 



2 26 DYSPNEA 

symptoms and the presence of a marked anemia are indicative of 
tuberculosis. 

Tuberculosis is usually developed anteriorly at first, and bron- 
chopneumonia posteriorly. If the condition has developed insid- 
iously, during the convalescence from one of the acute infectious 
diseases, it may be bronchopneumonia, but the strong probability 
is that it is tubercular. Occurring during the course of pertussis, 
it occasionally happens that a bronchopneumonia will persist until 
the pertussis has completely run its course. 

Generally speaking, it makes but little difference how irregular 
the course, or how persistent the disease present, if a thorough ex- 
amination shows beyond all doubt that the child was previously 
healthy, that there is no family tuberculous history or probability 
of infection, that the surroundings of the child were good, and that 
the disease developed under the influence of one or more of the 
usual etiologic factors of bronchopneumonia, then tuberculosis may 
be excluded as the cause. It is very evident that there cannot be 
complete certainty as to the exclusion of tuberculosis in these 
protracted cases, because, in the presence of some tuberculous 
predisposition it may complicate the original disease. 

There is always danger of diagnosing bronchopneumonia when 
the true condition may be malaria, and this is especially true 
if the malaria has been preceded by a bronchitis or if the onset is 
accompanied with congestion of the lungs, as it sometimes is. It 
is impossible, under such circumstances, to make a diagnosis with- 
out watching the temperature for some time. In bronchopneu- 
monia there are remissions of the temperature which may be marked, 
but there is never an intermittence, as in malaria. Enlarge- 
ment of the spleen would favor the diagnosis of malaria if the en- 
largement was marked, but not otherwise. 

The effect of proper treatment would aid in the distinction of 
the two diseases, but the demonstration of the plasmodium mala- 
rias in the blood would settle all doubt as to the presence of mala- 
rial infection. 

Congenital atelectasis would at times offer considerable difficulty 
in its distinction from bronchopneumonia during the first three 
months of life (after that it rarely, if ever, gives symptoms) . But 
atelectasis may be eliminated as the cause if the child has been well 



PLEUROPNEUMONIA 227 

and vigorous from the time of birth, and if, at the time of birth, 
there was no difficulty experienced in getting the infant to breathe. 
In atelectasis the physical signs are absent or doubtful and cyano- 
sis is not proportionate to the lung involvement, but is excessive. 

PLEUROPNEUMONIA 

If there is an excessive degree of pleurisy present in a case of 
pneumonia, then the condition is classed as a pleuropneumonia. 
While pleurisy is present in greater or less extent in all of the 
pneumonias of childhood except the hypostatic form, it follows 
the severity of the pneumonic process quite closely, and until it 
become excessive and predominates, the disease cannot be con- 
sidered as pleuropneumonia. It then modifies very much all of 
the other symptoms, and the two processes combine to form one 
clinical type of disease. 

The constitutional symptoms are all much intensified in pleuro- 
pneumonia, and it is this fact that usually serves to distinguish 
the affection. Even considering the severity of an ordinary 
pneumonia, the child in this disease exhibits the appearance of 
being much more seriously ill. The temperature is more constantly 
high, the prostration much earlier in appearance and greater 
in degree, the embarrassment to respiration is greater, and the 
thoracic pain is generally much more intense than in pneumonia. 
It is the severity of the constitutional symptoms which should 
at once lead to a physical examination, upon the results of which 
the diagnosis of pleuropneumonia depends. 

For the first two or three days the pleuritic friction sounds 
are characteristically prominent, and although after that the signs 
of consolidation are usually clearly defined, loud friction sounds 
still persist. When the exudate is abundant, the signs are less 
clearly defined, for there is an intermingling of the signs of con- 
solidation with the signs of an effusion, and the examination at 
this stage may for a time be misleading. However, if the pre- 
ceding history has been kept clearly in view, this will not be the 
case. Percussion exhibits marked dullness and possibly flatness. 
Bronchial voice and bronchial breathing indistinctly are in evi- 
dence, and vocal fremitus is diminished or absent altogether. 
Sometimes there are present coarse, crackling, pleuritic sounds. 



228 DYSPNEA 

As regards the extent of the different signs, they vary ; that is, 
they may be found over the whole of one lung, they may be limited 
to a single lobe, or more often are found posteriorly only. The 
signs may be confusing for a time, and there is only one thing 
which clearly distinguishes them from the signs which are present 
over fluid — that is, that the heart is not displaced. Puncture 
reveals nothing, as a rule, but by accidentally going into one of 
the many small pockets of pus, a few drops may be withdrawn. 



HYPOSTATIC PNEUMONIA 

This is a disease which develops directly as the result of an 
enfeebled circulation and a prolonged continuance in one position 
or continued decubitus. It develops in the course of some debili- 
tating disease. The condition is very similar to that which is 
presented by bronchopneumonia, in that both are generally 
bilateral and show a special preference for development at the 
lower portion of the lungs, posteriorly. 

Hypostatic pneumonia develops in this situation because of the 
position which the child assumes, and as dependent parts suffer, 
the back is almost always the site of the disease. The condition 
is not one which is, strictly speaking, inflammatory. In the 
beginning there is an embarrassed respiration or a weakened one, 
associated with the presence of small rales, and, later on, dullness 
upon percussion, bronchial respiration, and bronchophony. 

In the diagnosis there are two conditions which are present as 
etiologic factors — weak heart action and prolonged decubitus. 

When the heart action is fairly good, but the child has been 
confined to bed for a considerable period, the only sign of the 
affection may be the presence of crepitant rales, which are noted 
in the posterior and lower portions of the chest, upon deep inspira- 
tion. To detect this, however, the examination must be planned 
beforehand, for after two or three such deep respirations the 
rales are usually absent for a time. A similar condition might 
be present after the absorption of a large pleuritic exudate, but 
in that case there is the history of such. 

As a rule, when the percussion dullness is at all marked, it is 



PLEURITIS 229 

quite strictly limited to an area which is parallel with both sides 
of the vertebral column. This condition has led some to describe 
it as "strip pneumonia," which is certainly a forcible term. The 
affection usually occupies both the upper and lower lobes. 

If percussion dullness is absent (as is usually the case), then, 
in the same situation in which it is usually found, there may be 
detected only some fine moist rales, and if these are present and 
are associated with a clearing-up of the rales upon one or two 
deep inspirations, and this has occurred in a child who has been 
long confined, then the diagnosis of hypostatic pneumonia is 
reasonably certain, and the satisfaction is obtained of recognizing 
the condition before, and not simply at autopsy, as is usually the 
case. 

PLEURITIS 

This disease is not uncommon during the first five years of the 
child's life. It is closely associated with pneumonia, being almost 
constantly secondary to it, and as any chronic state of mal- 
nutrition predisposes to its occurrence, it is commonly observed 
during and after the devitalizing and infectious diseases of early 
childhood. The disease occurs in two forms — the dry and the 
exudative. 

The characteristic sign of the former is the friction rub, which 
is exactly similar to that which is observed in adults, but which 
in children is far from being as constant. It is heard during both 
inspiration and expiration and over a very limited area. If the 
stethoscope is pressed firmly over the part, there is an increase in 
the sound, but coughing fails to change its intensity or character. 

When exudation takes place, then there are signs of dullness on 
one side of the chest. This is at first noticeable posteriorly and 
in the lower portion of the chest, whence it spreads gradually 
upward and then finally forward, the level in front always being 
lower than that behind. 

Usually the onset is very abrupt, but at times the occurrence 
of the disease is so insidious that it is not discovered until the 
time that considerable exudation is present. There is an eleva- 
tion of the temperature which is not violent, but which is generally 
developed gradually to about 102 or 103 F., and then continues 



230 



DYSPNEA 



Hi 



with marked morning variations, ending by lysis in about three 
weeks. If the exudation be abundant or purulent, then the 
course may be protracted for six or eight weeks. 

As has been stated, the friction rub is not a constant feature in 
children, and usually it is not observed in the beginning of the 
disease, but later, when absorption is taking place. The pain 
which is present in most cases prevents the child taking a full 
and free inspiration, and so one of the best means of demon- 
mm ^^_ r _^^^^^^_ strating friction rub is eliminated 
■ from the examination. The pain 

£ is usually referred to the side of 

«»• the chest in older children, but in 

j -f*^ Jk infants, if it is evidenced at all 

^^•^k (usually it is not), it seems to be 

located in the epigastrium or um- 
bilical region. Sometimes the 
pain is not evidenced unless the 
pressure of the abdominal viscera 
upward causes it. 

Cough is a feature of the dis- 
ease which is present at the very 
beginning and persists with more 
or less severity to the end. It is 
short and restrained. The dry 
form may occur in children over 
nine or ten years of age, the same 
as it does in adult life, but under 
that age its occurrence is rare, and 
even then its diagnosis is open 
to serious question. It is the 
exudative form that interests us 
most, on account of its more common occurrence. When the exu- 
date is moderate, there is detected in the area of dullness vesic- 
ular but weakened breathing, which gives place to bronchial 
breathing when the exudate is considerable in amount. If the re- 
spiratory murmur disappears altogether, then we know that the 
compression is great and even the bronchi are involved in the 
pressure. With bronchial breathing there may be broncho- 
phony. 




Fig. 72.— Illustrating the point at 
which friction rub is most apt to be found 
in pleurisy. (Position of nipple intensi- 
fied by a circle.) 



PLEURITIS 



231 



Vocal fremitus is always weakened. When the exudation 
increases to such an extent that one-half of the chest is filled, then 
other symptoms are rapidly added. The child at once assumes 
and keeps the recumbent position, and upon the affected side, or 
may refuse to lie down at all. This is so because dyspnea, which 
is now more or less marked, is increased by the assumption of any 
other positions. 

The pressure of the fluid may obliterate the intercostal spaces 
and cause a unilateral bulging of the side of the chest. The heart 
is displaced by the fluid to the side opposite that containing the 
exudate. The liver and the spleen may also be displaced down- 
ward. If measurements are now taken, the affected side is found 
to expand less and is larger than the unaffected side. 



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Fig- 73-— Chart of the temperature ( ) and respirations ( ) in a ease of purulent pleurisy 

with death on the fourteenth day. Child ten months old. 

There are observed, occasionally, cases in which the exudate 
develops insidiously and with such insignificant general symptoms 
that they are overlooked. The child may have, for weeks before 
the examination, been getting pale and thin, is readily tired out. 
and suffers more or less from dyspnea. It is the last symptom 
which should at once arouse suspicion and result in a thorough 
examination of the chest and the evidences of the disease are at 
once marked, for by this time the fluid is abundant. 

It is not enough to recognize that an exudate is present — 
whether it be serous or purulent is very important. If the tem- 
perature assumes an intermittent type, if there are daily chills 
with more or less profuse perspiration, and the child becomes 
much wasted and pale, then its purulent character is evident. 



232 



DYSPNEA 



In those cases which have a remittent fever but an absence of 
the chills and sweats, the diagnosis is more difficult. Then several 
factors help one in the determination; the more abundant the 
exudate and the younger the child, the more probably it is puru- 
lent. If the exudate persists for over a month, it is probably 
purulent. Of the positive signs, there are the following: for- 
mation of abscess threatening an opening through the chest wall ; 
sudden expectoration of large amounts of pus; edema of the 
subcutaneous tissues on the affected side. Exploratory puncture 
may be necessary to clear up the doubt. In regard to such a 
procedure, this much may be said: that it is rarely necessary to 



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Fig. 74.— Chart of the temperature ( ), pulse ( ), and respirations ( — . — . — )ina 

ease of purulent pleurisy, with operation on the fourteenth day ; recovery. Child thirteen 
months old. 



make a deep puncture (two centimeters is usually all that is 
needful). 

Pleuritis must be clearly distinguished from that non-inflam- 
matory condition which occasionally occurs as part of a general 
edema — hydro thorax. Hydro thorax is almost always bilateral 
(although more evident upon one side than the other) ; the cause 
may usually be found (diseases of the kidneys, heart, or liver, or 
general wasting); there is no elevation of temperature and no 
pain; dyspnea and cough are slight, if present at all, and there 
are the other symptoms of the primary disease. 



THE CUTANEOUS SURFACE 

The study of the cutaneous surface is made with special reference 
to the color, the presence of rash or eruption, edema, scars, 
varicosities, and swellings, also of heat and moisture. 

THE COLOR OF THE SKIN 

At birth the infant's skin is usually more or less covered with 
a thick whitish substance (vernix caseosa) which consists of a 
mixture of epithelium, lanugo, and the product of sebaceous 
glands. The color of the underlying skin is generally a dusky 
blue, but after a few respirations this changes to the characteristic 
"boiled lobster" color of the healthy infant. After three or four 
days desquamation commences, and continues until about the 
end of the second week, and it is during this period that the 
hyperemia is so marked. After that time the skin should assume 
the characteristic pinkness of infancy. 

Pallor. — Pallor of the skin may appear suddenly or be of very 
gradual development. 

Sudden pallor is seen most often under the influence of excite- 
ment and of temporary heart weakness, as is observed during 
fainting, nausea, chills, and certain vasomotor disturbances. 
Other than this, it occurs whenever there is a large or rapid extrac- 
tion of blood from the body, so that frequently it is the first 
evidence which one has of an internal hemorrhage, being followed 
later by associated symptoms which depend upon the location 
and extent of the hemorrhage. 

Gradually developed pallor may be due to small but continuous 
hemorrhage or to a reduction in the number of blood-cells and 
hemoglobin. Such a reduction may be primary and so constitute 
a disease, or more often it is secondary to some chronic disease. 
These secondary anemias which cause the pallor are the usual 
accompaniment of acute nephritis, suppurative processes in 

2 33 



234 TH £ CUTANEOUS SURFACE 

general, tuberculosis of all types, and are especially early in evi- 
dence in the course of tuberculous meningitis and rachitis. The 
pallor of the skin in these cases is associated with other symptoms 
which are consequent upon an impoverished blood-supply, as, 
dyspnea upon exertion, muscular weakness, irritable nervous 
system, anorexia, and constipation. 

Pallor of the skin is a common accompaniment of all the ane- 
mias, but during childhood it is so frequently the case that this 
is by no means a marked constant feature that it is well to consider 
it in a separate section. This will be done subsequently, under 
the head of "The Anemias." 

It then only remains to mention the influence of some of the 
chronic poisonings, arsenical, mercurial, and malarial, in the pro- 
duction of gradually developed pallor. 

Yellow Tint. — Yellowish discoloration of the skin is a sign of 
jaundice, which is merely a symptom and not a disease. The 
development of this symptom depends less upon the nature of 
the disease than upon its location, the essential factor being 
obstruction to the exit flow of the bile. 

Icterus neonatorum occurs in about 60 per cent, of all new-born 
infants, and the cause is not fully understood. The diagnosis is 
made by a consideration of the age of the infant, as it begins upon 
the second or third day of life, upon the otherwise general good 
condition of the infant, the normal colored feces, and its very 
benign course. 

Icterus gravis of the newly born is always associated with high 
temperature, rapid collapse, and delirium, and usually has as 
accompaniments periarteritis or periphlebitis of the umbilical 
vessels. If there is an obstruction which is congenital, the feces 
are colorless or gray and the course of the condition is steadily 
unimproved, so that death usually occurs within a very few weeks, 
or perhaps may be delayed for months. 

When we come to consider the causes of jaundice in children 
past their infancy, we find that the most common of all causes 
is catarrhal inflammation. This may occur as a gastroduodenitis, 
catarrh of the common, large, or small bile-ducts, with swelling 
of the membranes. Or obstruction may be due to conditions 
other than inflammatory, interfering with the caliber of the duct. 



THE COLOR OF THE SKIN 235 

When due to some catarrhal inflammation, there is more or less 
pain referred to the epigastrium, the feces are colorless (a valuable 
guide in the distinction from toxemic jaundice), the tongue is 
coated, anorexia is marked, and fever moderate. In addition, the 
urine is usually much darker than normal and the liver enlarged 
and tender. The bowels may be either constipated or loose. 
The course of the disease is from a few days to two or three weeks. 

Toxemic jaundice is due to the presence of various poisons in 
the general circulation, and the symptoms are invariably very 
slight. The mild discoloration of the skin is the most noticeable 
feature, and is associated with feces which not only are normal in 
color, but may be darker than usual from an increased quantity 
of bile. It is chiefly of interest, as it is noticed during the course 
of some of the acute infectious diseases, especially malaria. 

Redness of the Skin. — Unusual redness of the skin is due to 
hyperemia which may be physiologic, as in blushing, from the 
reaction excited by warm baths, exercise, or friction of the cuta- 
neous surface, and from exposure to wind, heat, and cold. The 
erythema of the newly born has been mentioned in the beginning 
of this section. 

Diffused redness is observed during the course of most febrile 
diseases and is due especially to the very active capillary circulation 
of childhood. The administration of belladonna or its derivatives 
may produce diffuse redness, and if the child has an idiosyncrasy, 
the dose required may be unusually small. 

Localized redness is at times characteristic. In older children 
it is not uncommon to observe redness of one cheek in pneumonia 
and of both cheeks in pulmonary tuberculosis. Attacks of 
migraine may at times be evidenced chiefly by a unilateral 
redness of the face. 

Cyanosis. — Because of the thinness of the parts, cvanosis is 
first observed in the finger-nails, the lips, and the mucous mem- 
branes, and is evidenced by a bluish tint or purplish color of 
these parts and the skin. 

The development of cyanosis is favored by the following con- 
ditions: (a) Those which interfere with free access of air into the 
lungs, (b) Conditions within the lungs which limit its usual 
oxygen-supplying capacity, (c) Conditions which interfere with 



236 THE CUTANEOUS SURFACE 

pulmonary or systemic circulation, (d) Drugs which depress 
the respiratory center or which cause chemical changes in the 
blood. One or more of these conditions may be present in any 
given case. 

Generally speaking, the more rapid the development of the 
cyanosis, the greater the danger to life. The highest grade of 
cyanosis without a proportionately marked heart insufficiency is 
observed in congenital heart lesions. Cyanosis of this type is of 
the greatest value in the diagnosis of congenital heart disease. 
If associated with loud and diffused murmurs, it is practically 
positive evidence. The value of cyanosis in the diagnosis of 
these conditions is very great, but its absence would by no means 
exclude their existence, for occasionally congenital heart disease 
is marked without the appearance of any marked cyanosis. 

Cyanosis may be one of the most prominent symptoms of 
asphyxia neonatorum, and especially of that type which comes on 
after the infant has been respiring well for some minutes. The 
mucosa is particularly cyanosed, and the face assumes a bloated 
look. The action of the heart is much weakened. There is 
always some obstruction to the free entrance of air into the lungs. 
A circumscribed cyanosis which appears during the cold weather 
onlv is evidence of chilblain. 



RASHES AND ERUPTIONS 

The functions of the skin are so varied and important during 
the period of development, and there is such a dependence 
between these functions and those of general metabolism, that 
every disturbance, whether functional or structural, should receive 
the closest attention. There is no question of the importance of 
local causes for local lesions, but even when that is granted, the 
importance and frequency of constitutional causes is still marked. 
The more children one sees, the more this fact is impressed. 
Although few affections of the function or structure of the skin 
are limited to the period of childhood, yet the very fact that they 
occur during a period of rapid development gives to them peculiar 
characteristics, which are not so marked after the first few years 
of life. 



ERYTHEMATOUS ERUPTIONS 237 

ERYTHEMATOUS ERUPTIONS 

Under this heading we will include simple and inflammatory 
erythemas, whether diffused or localized. 

Erythema of the New-born. — This is a perfectly physiologic 
condition, appearing during the first few days of life. Reference 
has already been made to it in this section (see page 233). 

Dermatitis exfoliativa is very similar to erythema of the 
new-born, in that there is a diffuse redness of the whole cutaneous 
surface, the general condition of the infant remaining excellent, but, 
on the other hand, it is very dissimilar, in that it does not appear 
earlier than the fifth day of life (more often the eighth), nor later 
than the end of the third week. Another marked distinction is 
the course. 

In cases which are typical the first sign of redness is on the 
face, extending within twenty-four hours to the trunk and within 
forty-eight to the extremities. Usually within forty-eight hours 
of the first appearance of the redness desquamation is evident, 
and follows regularly the course of the redness — face, trunk, 
and extremities. 

At first there seems to be simply an unusual dryness of the 
skin as desquamation sets in, but later there may be exfoliation 
over large areas, with the underlying skin slightly moist and of a 
dusky red color. This redness becomes rapidly less dusky, so 
that within twenty-four hours it is simply a pinkish hue. 

The whole course of the disease is about one week, but it leaves 
the skin with a tendency to the development of other lesions. 
It is somewhat rare for the redness to become localized, but that 
may occur. A very unusual course is for the reddened surface to 
become studded with vesicles containing a clear fluid. These soon 
break and dry up, leaving no marks of any kind. 

Considering the absence of any constitutional symptoms, it 
does not seem possible that this disease could be mistaken for any 
other, except erythema of the new-born (and the differences 
have already been mentioned) and pemphigus. In this latter 
disease the blisters appear upon normal skin, while in dermatitis 
exfoliativa vesicles appear over already reddened surfaces. The 
course of pemphigus is much more protracted. At first a suspicion 



23§ 



THE CUTANEOUS SURFACE 



might be aroused, when the eruption appeared in an abortive 
infant, as to the possibility of hereditary syphilis, but the most 
superficial examination would exclude this possibility. 

Erysipelas. — Usually the eruption begins with the appearance 
of one or more closely adjoining red spots, raised slightly above 
the cutaneous surface, and accompanied with slight itching, 
which is evidenced by the child rubbing them. Then, as the 
redness spreads in various directions, there is added a sense of 
tension and pain. The appearance becomes rapidly characteristic, 
with sharply defined borders, markedly reddened appearance, 

and the more or less tense 
swelling of the very hot 
skin. From the central 
focus there may be various 
smaller processes over the 
healthy skin. It is peculiar 
of this inflammation that 
its spread is limited by the 
close adhesion of the skin 
to underlying parts, so 
that in those situations in 
which the skin is abundant 
in connective tissue the 
redness is decidedly limited. 
The acme of the inflam- 
mation in the skin is gen- 
erally reached in two or 
three days; then there is a 
gradual declination. Some- 
times this is accompanied with a lamellar desquamation, leaving 
the skin pale. Eight or nine days is the usual limit of the affection 
in a simple case, but if the disease shows a tendency to general 
distribution, the course may cover several weeks. Such a course 
as this latter is termed "erysipelas ambulans." Constitutional 
symptoms are severe. 

The inflammation of erysipelas being so typical, there is prac- 
tically no chance for error if the whole symptom-complex is in 
mind. Erythema exsudativum multiforme may exhibit lesions 




Fig. 75-— Lentigo (Winfield). 



ERYTHEMATOUS ERUPTIONS 239 

of limited extent, and the same be associated with more or less 
severe general symptoms, simulating erysipelas, but the etiologic 
factors are entirely different, and this is a rather rare condition 
in childhood. Diffuse phlegmonous inflammation simulates 
erysipelas more closely than any other condition, as it is charac- 
terized by redness and swelling with inflammation, but in these 
diffuse inflammations the redness is much darker than in erysipe- 
las, is not limited in any direction, and the skin has a hard, board- 
like feeling. 

Erythemas with Strict Localization. — Redness of the skin 
localized more or less strictly is due to some irritation of the skin, 
as a rule, and of this the history can be obtained, so that diagnosis 
is easy. The causes of the irritation may be varied: mustard 
plasters, local action of iodin, prolonged pressure, irritating 
excretions or secretions, etc. Another more diffused variety 
is that due to the action of the sun — caloric erythema. All these 
are readily diagnosed. 

Roseola JEstiva. — In children, ' with their unusually tender 
skins, various causes may produce eruptions which may add much 
difficulty to diagnosis. Etiologically, autointoxication is a most 
important factor, and in erythema multiforme probably the cause 
is some infection. The ingestion of certain foods will produce 
an urticaria in some children, and the rubbing or scratching of the 
spots will develop papules. 

Roseola is an eruption of a deep rose color. The spots are 
generally about the size of a pea, or they may appear a bit larger, 
and if so, are apt to be somewhat elevated above the surface. 
They are rounded or oval in shape. The spots do not appear 
independently, but are associated with other diseases, and usually 
those in which there is some febrile process due to infection of 
some kind. 

The rash is not diffuse and has no tendency to arrange itself in 
any particular order. It is only of interest as it occurs during the 
course of some of the diseases and makes the diagnosis more 
difficult. This source of error can be overcome to a great extent 
if one will refuse to be misled by the appearance of the rash alone, 
and will only consider it as it occurs with some associated disease. 



240 THE CUTANEOUS SURFACE 

It is apt to precede variola, scarlet fever, rubeola, typhoid fever, 
malaria, diphtheria, and syphilis. 

Occurring as a prodromal rash in variola, it indicates a mild 
form of the disease (petechias indicating a severe form). In this 
case it appears either in the form of diffuse redness over varying 
sized areas, or in the form of distinct spots which resemble rubeola 
spots but lack their characteristic arrangement. Such a rash 
lasts from twelve to forty-eight hours (usually the shorter period) . 

Roseola might be mistaken for the rash of scarlet fever, rubeola, 
or rubella, and the points of distinction are as follows : (a) Roseola 
is not contagious or epidemic, although it occurs with much 
greater frequency during some epidemics of the acute infectious 
diseases than in others, (b) There are no prodromata. (c) The 
rash does not follow any definite period or type of fever and is not 
limited to any special area or location, (d) There are no other 
symptoms besides the rash which can definitely be attributed 
to it, except a very moderate fever (ioo° or 10 1° F.). (e) It 
never appears in the mouth. 

The peculiarities of the syphilitic roseola are that it is not 
associated with any fever and is very chronic in its course, taking 
a long time to appear and a longer time to disappear. The 
hyperemia is soon complicated with pigmentation, but one must 
remember that the pigmentation which gives the so-called raw 
ham color is similar to that which is produced in all chronic 
dermatitis. 

Erythema Multiforme. — In a simple form this is observed as 
papules with or without exudation, and, as its name implies, the 
further course of the rash is mult form. It may disappear within 
a few hours or persist for two days. If the rash persists for more 
than a few hours, rings are usually formed, and with the fading 
of the color desquamation takes place, leaving a few pigmented 
spots. 

There is never any itching or pain, and if fever is present at all, 
it is only at the onset and then moderately. This rash shows a 
particular preference for the dorsal surfaces of the wrists and the 
feet. If the special localization is remembered, and consideration 
is taken of the multiformity of the rash and its short duration, 
there is practically no chance for mistaking it. 



ERYTHEMATOUS ERUPTIONS 



2 4 I 



Erythema Nodosum. — With the erythema there is considerable 
edema. The eruption is caused by serous exudation into the 
skin, so that flat elevations are formed from the size of a pea to 
that of a chestnut. The redness of the nodules is modified some- 
what by the color due to venous congestion, so that in most 
instances the spots look bruised. Occasionally, however, the 
spots may remain red for a time and fade away without change 
of color. 

The patches develop 
usually on the legs and 
forearms, their long dia- 
meters being parallel to 
the long axis of the 
bones. It is rare to find 
them in any other situa- 
tions. The spots are 
often quite painful, are 
invariably tender, but 
never itch. A rise in the 
temperature when the 
nodules appear is very 
common, and this is so 
even when they are few 
in number. 

When the edema is at 
all marked, the nodules 
may readily be mistaken 
for periostitis, but the 
appearance of nodes upon 
other remote parts would 
at once clear up any doubt, 
tinguish it from urticaria. 

Urticaria. — This is so common during childhood, and is so 
frequently associated with digestive disturbances, that it has 
come to be considered as indicative of such. The characteristic 
eruption is the formation of wheals with white centers and sur- 
rounded with an erythematous blush. They appear suddenly, 
and when conditions are right, may be produced by rubbing or 
16 




Fig. 76. — Pemphigus vulgaris (Winl 



The absence of itching would dis- 



242 



THE CUTANEOUS SURFACE 



scratching, so that very often the intense and persistent itching 
which is characteristic not only is not relieved by scratching, but 
is intensified by it. Several wheals are formed, as a rule, which 
persist for a few hours or days. A much less common form is 
that in which large areas are affected as the result of the coales- 
cence of several small patches. All parts of the body may be 
affected except the scalp and the soles of the feet, and affection 

of the face is very rare. 

The course may be 
acute or chronic, and in 
the latter it is charac- 
terized by the appearance 
of many successive crops 
running into one another. 
Medicinal Rashes. — 
The diagnosis of these is 
very easy if a clear his- 
tory is obtainable, but this 
is not always the case. 
Belladonna may cause a 
rash which is quite similar 
to that of scarlet fever, 
but which lacks the 
minute darker points 
which are seen in the 
latter. Antipyrin may 
be the cause of an erup- 
tion which looks like 
urticaria (but with no intense itching) or like rubeola (without 
the crescentic arrangement). For other rashes see following 
sections or index. 

Erythema scarlatiniforme and erythema morbilliforme are 
considered where such consideration will be of most service, under 
"Infectious Diseases." 




Fig. 77.— Lupus vulgaris (Winfield). 



VESICULAR ERUPTIONS 243 

VESICULAR ERUPTIONS 

Medicinal Rashes. — Atropin may at times produce a rash 
which is vesicopapular and somewhat simulates acne, but such a 
rash is developed upon an inflammatory base and is much more 
superficial than acne. 

Herpes. — This is evident by an eruption of vesicles arranged in 
groups or clusters upon an inflamed base or surface, and from 
the location of the lesion it receives different names, as frontalis, 
facialis, zoster, etc. 

Herpes facialis appears usually upon the lip or the alae of the 
nose, but sometimes may appear on the cheek or chin or within the 
mouth. The appearance is rather sudden and unattended with 




Fig. 78.— Zoster of arm and palm of hand (Winfield). 

any pain. Within about three days the vesicles dry up, forming 
thin, small crusts. It is always evidence of some internal disorder, 
usually a catarrhal inflammation of the respiratory tract or mala- 
ria. 

Its common occurrence during the course of pneumonia and of 
epidemic meningitis gives to it a position of quite some value in 
diagnosis. On the other hand, it never occurs during tuberculous 
meningitis or typhoid, so that that fact may often be of service in 
differentiation. 

Herpes zoster is another form of the affection which is character- 
ized by appearing over the course of a nerve. Unlike the adult 



244 THE CUTANEOUS SURFACE 

type, it is not accompanied by neuralgic pain, either during or 
after the eruption. Preceding its appearance, however, there may 
be more or less burning feeling over the affected area. The vesi- 
cles are at first discrete, finally tending to coalesce, and when un- 
disturbed, they form scabs which, when they drop off, leave the 
skin slightly reddened. 

The duration of the affection is usually about one week. 

Sudamina. — This is a form of miliaria in which there is no in- 
flammation. Tiny vesicles appear, looking like small pearly 
bodies closely set together. Disappearance is accomplished by ab- 
sorption within a very few days, but fresh crops may appear from 
time to time. Such a condition may be observed during the course 
of any fever or when exhausting conditions are present. 

Eczema frequently shows vesicular eruption, but as the lesions 
are so varied, I think that it is best to give it a separate considera- 
tion, which will be done later (see page 250). 

Varicella is also considered under another heading (see "Infec- 
tious Diseases"). 

PAPULAR ERUPTIONS 

Miliaria Rubra. — This is usually the result of overdressing and 
is a sweat rash. Its common occurrence is upon the neck and 
cheeks. The eruption consists of red papules which are scattered 
and sometimes interspersed with tiny vesicles. Itching, if present 
at all, is very slight. 

Miliaria Papulosa. — This is the commonest variety of miliaria 
and is popularly known as prickly heat. The red papules which 
appear are very fine and very thickly set. Occasionally there are 
seen scattered over the eruption tiny vesicles which occupy the 
summit of some of the papules, or in rare cases there may be mi- 
nute pustules present. If undisturbed, the vesicles will dry up, 
and are followed with a slight desquamation. 

The appearance of the rash is characteristically rapid, especiallv 
upon the neck, back, and chest. The itching which accompanies 
the appearance is at times almost intolerable, which in a young 
infant may cause a long train of symptoms. The duration is about 
forty-eight hours. 

From eczema the diagnosis is easy, for miliaria appears so sud- 



PUSTULAR ERUPTIONS 245 

denly and is of such short duration. It never occurs in circum- 
scribed areas like eczema, being more or less diffused. Another 
very valuable sign is that sweating is usually very profuse over the 
portions of the body not affected by the rash. 



PUSTULAR ERUPTIONS 

Medicinal Rashes. — The bromids produce very frequently 
a pustular eruption, which appears most often upon the shoulders, 
chest, face, and arms. The iodids may produce a similar pustular 
eruption (or the rash may be papular or erythematous), but show 
a special preference for the face, neck, and arms. The history is 
usually all that is necessary to clear up the character of the rash. 

Gangrenous Dermatitis. — This is a rare condition and is ob- 
served almost exclusively in infancy. The eruption is usually 
first seen as a vesicle about the size of a pea, but this rapidly be- 
comes pustular with a dark-red areola. When the pustules break, 
crusts form which are very adherent, with ulceration underneath. 
These ulcers are sharply defined and may coalesce. It occurs only 
among the most neglected children. 



ERUPTIONS WITH THE FORMATION OF CRUSTS AND SCALES 

Ichthyosis is usually looked upon as a congenital deformity 
and not as a disease. It is always hereditary, although not neces- 
sarily congenital, and, outside of the hereditary tendency, we 
know practically nothing in regard to its cause. 

Without entering into a lengthy discussion, which would be 
possible, in regard to this disease, it may be stated that any chronic 
non-inflammatory condition of the skin which results in the skin 
becoming dry and parchment-like, while at the same time the 
flexor surfaces are spared, is ichthyosis. 

In the severest form the infant dies within a few days. The epi- 
dermal layer of any part of the bodv may be cracked in irregular 
shapes, the loosened edges of which turn up like the scales of fish. 
The scaly skin is of a gray color, with the fissures of a raw red hue. 

Occurring late in infancy, the disease is subject to some varia- 
tions in its intensity, for at this time it is more chronic. The gen- 



246 



THE CUTANEOUS SURFACE 



eral health then has a marked influence upon the disease and cold 
weather makes it worse. 

The course is chronic and without hope of cure. 
The diagnosis is easy, although the disease is so rare, because of 
its typical character and the absence of subjective symptoms. 

Seborrhea. — When the sebaceous glands are overactive, the 
discharged contents gather upon the cutaneous surface in the form 
of an oily exudate or of dry, friable crusts, and this constitutes 
seborrhea. 

The affection usually occurs during infancy, as seborrhcea capitis, 
and the anterior fontanelle is generally covered with thin, dry, 
dirty yellow colored scales which adhere firmlv to the scalp. The 

whole head may become 
affected, even down to 
the eyebrows. Under 
the scales the skin is 
reddened slightly, but 
there is no inflamma- 
tion. 

The occurrence of the 
affection should lead to 
an investigation of the 
state of the nutritive 
processes, as it most 
often occurs in infants 
whose nutrition is faulty 
or whose general health 
is poor. The affection generally disappears after the nursing 
period, but there may be returns of the trouble. 

Impetigo Contagiosa. — This disease of the skin is usually not 
seen until crusts have been formed. At the start the lesions are 
discrete vesiculopustular ones, but crusts are very quickly formed, 
so that this latter is the condition for which the physician is gener- 
ally consulted. The lesions show a preference for the face, and 
especially the lower part of the same, but they extend by inocula- 
tion to the more accessible parts of the body. 

The first appearance of the eruption is that of a small, flat, and 
soft vesicle with a central depression as the periphery extends and 




Fig. 79. — Ichthyosis < Winfield) 



ERUPTIONS WITH THE FORMATION OF CRUSTS AND SCALES 247 

becomes pustular. This may increase until it is about the size of 
a dime. The contents then are expelled or exude, forming a yel- 
lowish crust, which falls off at the end of seven to twelve days, 
leaving the cutaneous surface but slightly reddened for a time. 
While the crust remains, it is in strong contrast to the healthy skin. 
The lesions may coalesce so that, instead of the usual appearance, 
one sees large patches where the crusts have run into one another. 
Itching is not a marked feature, but is sufficient to cause scratch- 
ing, and thereby an extension of the affection to other parts or 
the formation of ulcerations from the irritation. 

The diagnosis must be made by a consideration of the history 
(contagion) and the extension by inoculation, as well as by the 
appearance of the lesions. The disease is most apt to occur dur- 
ing the first eight months of life. 

Tinea Favosa (Favus). — This is a highly contagious disease 
and may be contracted either from human beings or from animals. 
No age is free from it, but it shows a remarkable preference for the 
young and those of uncleanly habits. The favorite situation for 
it is upon the scalp, although not limited to that part. 

The lesion upon the scalp is usually of circumscribed yellowish 
crusts with cup-like depressions. These areas extend and the cup- 
like depressions thicken, until the whole of the scalp may be cov- 
ered. When the crusts are removed, the underlying surface is 
devoid of hair, is slightly reddened, and is somewhat depressed. 
There is present at this time a peculiar musty odor which is quite 
characteristic of the disease. 

Unless the case is very typical in its development and in its le- 
sions, a microscopic examination should be made to find the para- 
site. The decided yellow color of the crusts will serve somewhat in 
distinguishing the disease from eczema, which exhibits crusts of a 
brown hue, but if the case is one of long standing, the color will not 
be so pronounced ; then more dependence is placed upon the oc- 
currence of baldness, which is so prominent in tinea favosa and not 
so evident in eczema. 

The course of tinea favosa is essentially chronic, persisting often 
for months. 

Tinea Trichophytina (Ringworm). — This disease is named. 
according to the location of the lesions, tinea corporis or cirein- 



248 THE CUTANEOUS SURFACE 

ata, tinea capitis or tonsurans, and tinea unguium or onychomyco- 
sis. It is a parasitic disease, due to the trichophyton fungus and 
other yarieties of fungus. The infection of a child may come 
through human agency or may be directly from animals. 

Tinea corporis usually begins as a slightly raised circular spot, 
with a very reddened surface, and appears upon the parts devoid 
of hair. From being about the size of a pea, it may extend until it 
is one or two inches across, and during the process of extension the 
central portion resumes the appearance of normal skin, while the 
periphery is a ring of minute red papules and vesicles undergoing 
desquamation. The desquamation is of a fine, scaly character. 
Several of the rings may coalesce, forming irregular patches. The 
lesion persists for several weeks, finally subsiding, while new le- 
sions are formed in other parts. 

Tinea unguium affects the nails and is rather a rare condition 
during childhood. 

Tinea capitis is by far the most common form, involving not 
only the epidermis, but also the hair-follicles, the sheath, and 
the capillar} 7 cylinders. The lesions are circular and increase by 
peripheral extension. In the beginning attention is usually called 
to the presence of a circumscribed bald patch, and upon close ex- 
amination this is found to be an elevation covered with very fine 
white scales which look like powder. Removal of the scales leaves 
the underlying surface slightly red in color (or in some instances 
there is a dusky bluish hue). The surface shows the presence of 
broken-off hairs, while the hairs at the periphery are lusterless and 
very dry. There may be some itching. The course of the disease 
is chronic. Unless the disease is typical, reliance for diagnosis 
must be placed upon microscopic examination. 

Psoriasis. — This disease is milder, easier to treat, and more dis- 
crete than the similar condition in the adult. It is of very rare 
occurrence before the sixth year, so that a consideration of the age 
is a valued point in differential diagnosis, although one must not 
forget that in rare instances it may occur as early as the first year 
of life. 

The disease never attacks the hands or the feet, but shows a 
characteristic preference for the flexor surfaces. It is evidenced 
by abundant pearly scales which are thickly crowded over the 



LOCALIZED PRURITUS 249 

healthy skin. The scales when formed are very abundant, and 
when removed leave a bleeding surface. 

The differentiation must be made from eczema. The crusts of 
seborrhea are friable and of a greasy feel, and their removal leaves 
a pale surface and not a bleeding one, as in psoriasis. The scales 
of syphilis are of a dirty brown color and are often found upon the 
hands and feet. Other symptoms of syphilis are so marked that 
there is practically no chance for error. 



LOCALIZED PRURITUS 

The administration of the opiates in some children will result in 
a scarlet rash which is accompanied with intense itching, or more 
commonly there is an itching which is limited to the region of the 
nose and unaccompanied with any rash. 

Scabies. — This is a contagious disease of the skin due to the bur- 
rowing of the female acarus. The favorite situations are where the 
skin is the thinnest, so that we find the lesions usually between the 
fingers, on the flexor surfaces of the wrists, in the axillae, and on the 
genitals in males. An infant at the breast of an infected nurse may 
show lesions about the face. The lesion is a papule or a vesicle, 
more rarely a pustule, and there may or may not be inflammation 
present. The lesion is due to the formation of the burrow and ap- 
pears as a fine brown or black line about one-quarter to one-half 
inch long, with a whitish speck at one end, which is the acarus. 

Usually the inflammation which accompanies this is in direct 
proportion to the general health of the child. The inflammation 
may be so severe that the parts affected are simply a mass of pus- 
tules, and such an eruption on the hands should always suggest 
scabies. Added to these are lesions which are the direct result of 
scratching. 

The diagnosis is easy if there is obtainable a history of other 
cases, but without this the characteristic feature of the eruption 
is the presence of papules, vesicles, or pustules in parts where the 
skin is thin. A small magnifying glass will rarely fail in the de- 
tection of the burrows. A vesicular form of urticaria occurring in 
infancy may readily be mistaken for scabies, or vice versa, unless 



250 THE CUTANEOUS SURFACE 

one has had the chance to see the development of the eruption. 
Itching is very marked. 

Pediculosis. — Pediculosis capitis is very common after the 
school age, and occasionally it is prevalent among younger children 
who are neglected. The ova (nits) clinging to the hair may for a 
time be the only evidence of the presence of lice, which are observed 
later as minute dark-red spots lying close to the skin, and which 
when disturbed show much activity. The itching is usually 
quite persistent and severe. 



PIGMENTATIONS OF THE SKIN 

Nevi (Birth-marks). — These are of two forms — the pigmented 
and the vascular. The former consists simply of a circumscribed 
hyperpigmentation of the skin, or it may be warty and covered 
with hair. An increase in size may occur as the infant develops. 
The vascular forms are composed of anomalous blood-vessels of all 
kinds, and may not be discoverable at birth, but develop later. 
Their size, shape, and situation are very variable, but in one par- 
ticular they are all alike — they are obliterated for a time by pres- 
sure. When they are developed to a great extent, they are called 
angiomata cavernosa. 

Xeroderma pigmentosum is a very rare disease, beginning in 
infancy as early as the second or third month, and is distinctly 
hereditary. The primary appearance of the lesions is similar to 
ordinary freckles, but the intervening spaces soon exhibit depres- 
sions which resemble variola scars. Several areas develop later 
which show hyperemia, telangiectasis, and soft warty growths, 
until all the exposed surfaces are the site of some one of these lesions. 
Ulceration and atrophy follow in a persistently chronic course. 



ECZEMA 

Eczema is certainly the most important and potentially is the 
commonest skin disease of childhood. The forms of the affection 
are various, and principally because there is so much difference in 
the severity. The disease may properly be regarded as a catar- 
rhal inflammation of the skin with varied developmental changes. 



ECZEMA 



251 



After the age of seven or eight the disease does not show any 
differences from the adult type, so that its consideration here will 
be chiefly as it occurs in young children and infants. The sensi- 
tive skin of the young child predisposes to its development, and 
the relation of the disease to gastro-intestmal disorders is also inti- 
mate. Anything which renders the natural resistance of the child 
less strong favors the development 
of eczema, and if added to this is 
some slight irritation of the sensi- 
tive skin, the disease is apt to 
follow. 

The ordinary chronic form 
(eczema rubrum) is the most 
common, and its usual location is 
upon any part of the face or 
hands (but it may extend over the 
body). The appearance of the 
lesion at first is usually a few 
small scattered papules which 
break down and expose a raw and 
moist surface. This surface exudes 
serum and seropus, which finally 
dry up and form thick gummy 
crusts which may be quite hard. 
Scratching causes these to bleed 
readily, and if much blood is 
drawn, the crusts become a dirty 
brown color. The skin may be 
more or less swollen. 

If the crusts are removed, the 
underlying surfaces are red, in- 
flamed, and perhaps granular, 

or, in more chronic cases, there may be some thickening and 
induration. The itching is a very marked feature. Swelling of 
the lymph-nodes about the eruption is a constant feature of the 
disease when it affects the scalp or face. Both dermal and adeni- 
tic disorders may spread indefinitely and are essentially chronic 
in their course. 




Fig. 80.— Eczema (anterior view) (Win- 
field). 



252 



THE CUTANEOUS SURFACE 



Seborrheic eczema is in reality a combination of seborrhea and 
eczema. The favorite location is the scalp and face at first, whence 
it spreads to the neck, chest, back, and arms, or to any other part 
of the body. The primary lesions are usually those of a dry sebor- 
rhea with the formation of yellowish crusts. The skin is not thick- 
ened nor is there any apparent elevation. Itching is not so severe 
as in the commoner form, nor is there any extensive weeping sur- 
face. The crusts are very soft. The patches are inclined to be 

sharply defined, although the lesions 
are not deep-seated. 

Intertrigo is really eczematous only 
in a potential sense, and is a term 
which is commonly applied to any 
eruption which develops upon two 
moist surfaces which are in contact. 
Its cause is any uncleanliness, so that 
it is commonly seen in the groin, the 
axillae, about the buttocks, back of 
the ears, and about the genitals. In 
the beginning there is a reddening of 
the skin in a patch or more, which 
usually becomes exaggerated, so that 
the upper layers of the epithelium are 
thrown off and an eczematous process 
begins. Crusts are not formed, but 
the itching, tenderness, and pain are 
all severe, as a rule. 

Pustular eczema affects the scalp 
most commonly, because the condi- 
tions are favorable for pus-formation. 
It is simply an eczema with added in- 
fection with septic microorganisms. Itching is not severe. 

The diagnosis of eczema does not present as much difficulty as- 
is commonly supposed. Usually the development of the disease is 
quite typical, so that there is less chance of being misled. In 
addition to this we observed two very essential and characteristic 
signs of the disease — considerable itching of the parts and swelling 
of the neighboring lymph- nodes. 




Fig. 81. — Eczema (posterior view) 
(Winfield). 



PURPURA 253 

There might be some difficulty in differentiating scabies, for 
this disease simulates eczema in these particulars — intense itch- 
ing and multiform lesions. But in scabies there is usually the his- 
tory of other cases in the families or among the playmates; the 
parts affected are the flexures of the wrists and elbows, or between 
the fingers, the axillae, and, in males, the genitals. A detection of 
the burrows would clear up any doubt. 

Papular eczema of the buttocks might, under some circum- 
stances, be mistaken for syphilis, but the former disease affects the 
parts near the anus and not directly at the anus. However, it is 
often impossible to make a satisfactory distinction without going 
into the history very carefully and searching for other signs of 
syphilis. The syphilitic eruption does not itch at all, and inflam- 
mation is not much in evidence. The eruption also occurs as 
small circumscribed spots and exhibits a dark color. 



PURPURA 

This cannot be considered as a disease ; it is simply a symptom. 
By it we understand the existence of a condition which occurs 
spontaneously, and the chief characteristic of which is transitory 
hemorrhages of the external skin, mucous and serous membranes, 
as well as parenchymatous hemorrhages of the internal organs. 
Purpura simplex includes hemorrhages of the skin alone, while 
purpura haemorrhagica includes bleeding into the skin, the mucous 
and serous membranes, and the internal organs. 

Outside of these two larger classifications there are almost 
innumerable others, which are based upon the associated disease 
or upon the apparent cause of the hemorrhages, but as all of 
them finally depend upon a general cause, there is no necessity 
of considering them separately. 

Purpura simplex is, of course, the mildest form of the condition, 
but one is never certain that it will remain so. It may soon run 
into the more severe form, and there are no clear marks of dis- 
tinction in the transition from one type to the other. It is only 
with the greatest circumspection that distinctions are presum- 
ably made. In most instances it is impossible to determine any 
immediate cause for the occurrence of the condition. It probably 



254 TH E CUTANEOUS SURFACE 

depends upon some internal causes of which we know nothing at 
present. 

The mild form is evidenced by the appearance of extravasa- 
tions of blood in the skin, which are fine, discrete, pinhead-sized, 
red spots (petechiae), which do not disappear upon pressure. 
These spots are the only clinical symptom. The spots may 
remain in evidence for a few hours only, or they may persist for 
several days. When the condition is more severe, then the 
hemorrhages in the skin appear as small but very numerous dusky 
red, circular spots, which show much preference for the lower 
legs and the feet, the arms, and the abdomen. In time these 
spots undergo the usual alterations in color which are observed in 
all extravasations of hemoglobin. After a few days they become 
quite pale, and finally fade away entirely, but there may be several 
crops of the spots from time to time. The greatest source of 
error in their differentiation may be from the bites of insects, 
and especially of fleas, but in the latter instance there are always 
uniformity of size, central puncture, and sometimes the evidences 
of itching. 

Purpura hemorrhagica represents a very severe and tenacious 
form of the condition, for the hemorrhages are almost always 
extensive and profuse, so that at times the child has the appear- 
ance of having been spattered with blood. In this form there is 
often seen every degree of hemorrhage from a simple petechia to 
large areas in which the blood has arranged itself in irregular 
forms. When the mucous membranes are much involved, the 
nose is usually the first to suffer, so that epistaxis is an early 
occurrence, being followed rapidly by hemorrhages from the lips, 
cheek, gums, and palate. 

Naturally, one encounters all grades of anemia, with consequent 
symptoms and results. Occasionally urticaria will develop, and 
if so, the urticarial spots are the sites of hemorrhages. When the 
condition occurs, associated with a high temperature, a suspicion 
might be aroused of hemorrhagic variola. In favor of the disease 
we have the history of exposure (without the protection afforded 
by a recent vaccination), and the peculiar fact that when petechiae 
appear as a part of the condition which makes the disease hem- 



PURPURA 255 

orrhagic, they appear first upon the lower part of the abdomen 
and the inner aspect of the thigh. 

Typhoid might be suspected if fever was present for several 
days previous to the appearance of petechias, but if the character 
and type of the temperature had been observed, no mistake could 
reasonably happen. Other symptoms would appear which would 
not allow of any doubt as to the cause being typhoid. 

A very great difficulty will arise, in certain atypical cases, in 
distinguishing purpura from the hemorrhages which occur during 
the course of scurvy. In scurvy, however, the hemorrhages into 
the muscles, under the periosteum, and in the cellular tissue are 
very frequent, and bleeding from the mucous membranes is not 




Fig. 82. — Purpura haemorrhagica (Little). 

apt to occur until very late in the disease ; in purpura the reverse 
is true. The bleeding in scurvy is not strictly from the mucous 
membranes, but from points of ulceration about the gums, and 
this ulceration is manifested by swelling of considerable degree 
and a disagreeable odor. In purpura the mucous membrane 
remains perfectly normal, although the site of considerable 
hemorrhage. 

There is not only a hemorrhagic condition during the course of 
scurvy, but added to it is an inflammatory element, while in 
purpura the hemorrhagic element is pure. Then, again, in the 
former disease, before the occurrence of hemorrhages, there arc 
well-defined symptoms of a general nature, which point clearly 



256 THE CUTANEOUS SURFACE 

to some fault in the nutritive processes with a long train of symp- 
toms which are dependent upon the malnutrition and the weak- 
ness present ; but in the latter condition the symptoms of anemia 
and weakness, if present at all, follow the occurrence of hemor- 
rhages. If doubt still existed after a consideration of all of the 
foregoing facts, the history of the child's feeding from the time 
of birth, and of all of the symptoms past and present, and the 
effect of the administration of the vegetable or fruit acids would 
be a valuable aid. 

In 1 868 Henoch first noticed that purpura and arthritic phenom- 
ena might be associated with vomiting, colic, and hemorrhagic 
diarrhea, and this condition is known as "Henoch's purpura"; 
and this, with our present knowledge, should be regarded not as 
a special form, but as a special manifestation of the same tran- 
sitory hemorrhagic tendency as is observed in all purpuras. 



EDEMA 

If there is an accumulation of serum in the lymph-space of 
the subcutaneous connective tissue, it is commonly called dropsy. 
If such an accumulation is confined to rather small areas, it is 
termed edema ; if the accumulation is very general, and in addition 
the large lymph-cavities, the pleura, the pericardium, and the 
peritoneum are involved, then we use the term anasarca. 

The accumulations of lymph in the lymphatic vessels and spaces 
and also in the serous cavities may be influenced by the excessive 
formation of lymph, by interference with its free escape (or both 
causes acting together), or by hindered flow of the lymph. The 
escape of the lymph from the capillaries depends to a great degree 
upon the differences in pressure between that of the blood in the 
capillaries and that of the tissue which surrounds them, as well 
as upon the permeability of the capillary wall. 

Edema may be caused by venous stasis, which may, in turn, 
be merely local (occlusion of the vein), or it may be general, as 
when due to pathologic conditions in the lungs, to cardiac weak- 
ness, to intrathoracic growths, or to exudates (pleural or pericar- 
dial). Naturally enough, most of the swelling is in the line of the 
least resistance, so that elastic tissues and organs suffer most, or, 



EDEMA 



257 



again those parts which are most dependent. It is for this 
reason that edema from general stasis shows a preference for the 
ankles and lower parts of the back. 

No matter what the extent of the accumulation, the recognition 
of the condition is not at all difficult. The part affected is swollen 
and puffy, wi h a smooth and pale surface which may be very shiny, 
and upon pressure pitting is observed which persists for an appre- 
ciable time. This pitting is most pronounced when pressure is 
made over some part which has a hard or bony background. 

By the occurrence of much edema the natural lines and depres- 
sions of the part are all ob- 
literated, and this may 
amount to deformity of 
the part. It is quite char- 
acteristic of the condition 
that it is influenced by 
position, and even inde- 
pendent of this, it shows a 
tendency to disappear in 
one part to reappear in 
another. 

From inflammatory 
swelling it is distinguished 
by the absence of the 
classic signs of pain, red- 
ness, and heat. Subcutan- 
eous emphysema gives a 
crackling sound upon pres- 
sure, there is no pitting, and this condition is always associated 
with some disease or condition of the air-passages. As a diag- 
nostic sign its value is influenced by its location, the mode of 
development, and the disease with which it may be associ- 
ated. 

Local Edema. — This occurs under the influence of pressure 
upon or interference with venous circulation. It is also a valuable 
diagnostic sign of inflammation An inflammatory edema occurs 
because inflammatory processes hinder the free removal of lymph 
from the tissues and in addition injure the capillary walls. 
17 




Fig- 83. — Mastoid abscess. The characteristic 
mariner in which the external ear is pushed forward 
by the abscess is here well shown. 



258 THE CUTANEOUS SURFACE 

One Arm. — This indicates some pressure upon the axillary or 
subclavian veins (or thrombosis of the same), either from injury, 
tumors, or enlarged axillary glands. 

One Leg. — The causes which have been mentioned as affecting 
the arm may, by corresponding conditions in the groin and thigh, 
bring about similar conditions in the leg, by causing pressure over 
the femoral vein. 

The Feet. — This may occur in a debilitating or exhausting 
disease, in which the heart action has become weakened, there- 
fore it is not uncommon during the diarrheas which run a chronic 
course. On account of more perfect compensation, it is not so 
frequently an accompaniment of cardiac disease as the similar 
condition is in adult life. It is very common during all the forms 
of anemia. 

The Face. — This gives to the face a very striking appearance, 
and is strongly indicative of some renal disease. Its appearance 
is most marked in the morning. Occasionally it accompanies 
inflammatory processes in the skin (as in some cases of urticaria). 
A chronic edema of the face may be due to a remote attack of 
erysipelas. 

Unilateral edema of the face accompanied with some elevation 
of temperature, but no redness of the skin, may be due to the 
presence of an alveolar abscess or to parotiditis. If there is an 
odor from the mouth which is fetid, and the child is evidently 
exhausted and debilitated, it is strongly suggestive of noma. 
Edema of the eyelid alone indicates an inflammatory condition of 
the eye and is not suggestive of renal disease, as is sometimes 
taught. 

The Neck. — Edema of the neck which is painless, without signs 
of inflammation on the skin, generally means that there is an 
inflammation of some adjacent organ, and search should be made 
for periostitis of the inferior maxillary, for diphtheria, tonsillitis, 
and parotiditis. When diphtheria is the cause, the swelling is 
usually bilateral; in tonsillitis it is more often unilateral, and in 
parotiditis the swelling is directly under the ear and characteris- 
tically harder in that situation than elsewhere. 

The Chest. — If limited to one side of the chest, edema indicates 
that there is a purulent pleurisy. 



EDEMA 259 

Angioneurotic edema is a circumscribed type. Its appearance 
is sudden, it remains but a short time in evidence, and disappears 
as rapidly as it came. It is generally preceded by local symptoms 
of itching, heat, and redness, or by a general urticarial eruption. 
With the attack there is usually associated some gastro-intestinal 
disturbance, which may be severe, with vomiting and severe 
colic as the chief symptoms. The boundaries are sharply defined. 
The absence of any itching helps to distinguish this from urticaria 
(if itching is evident it is only before the appearance of the swell- 
ing), although the two may be associated. 

General Edema 

Sclerema neonatorum is a hardening of the cellular tissue 
which occurs in nurslings. The skin of the legs, and later that 
of the whole body, hardens, and associated with it there is a general 
collapse. There are two forms of the disease — the acute, which 
affects the new-born, and the other (sclerema adiposum), which 
develops in later childhood (after several months of life). The 
latter usually develops under the influence of profuse diarrhea. 
As far as diagnostic value is concerned, there is none, except as 
the condition gives evidence that the infant is weak or abortive. 

Anasarca. — This is in most cases dependent upon disease of 
the kidneys (nephritis) and is much less frequently due to cardiac 
disease. However, independent of either of these conditions, it 
may develop under the influence of general exhaustion, and 
especially that which follows some acute disease. In this latter 
type there is no albuminuria and the swelling is generally confined 
to the abdomen and the ankles, but may extend up the legs. 

Myxedema closely simulates dropsy, and the swelling is general. 
A peculiar characteristic, however, is the fact that the legs are 
more swollen than the feet and the arms more than the hands, 
and the swelling of both legs and arms is irregular. There may 
be several areas of padding. In this condition the thyroid gland 
is always absent, actually or functionally. The swelling does not 
pit, but is hard and indurating, and associated with most striking 
changes in the general appearance. The skin is thick, dry. and 
rough, sometimes with a gloss to it. There is considerable mental 
deficiency, which may border upon idiocy. 



260 THE CUTANEOUS SURFACE 

SCARS AND CICATRICES 

Small round depressions or pits upon trie cutaneous surface are 
indicative of a past attack of variola or varicella, and as corrob- 
orative evidence of the history of such attacks have some value. 

Small irregular scars with a hardened feel may be the result 
of furuncles, and the favorite situation of these is about the neck. 
These latter, however, must not be confused with the large irregu- 
lar scars which are due to scrofulous or tuberculous glands. These 
latter are almost uniformly depressed and more or less adherent. 
They show a special preference for the cervical, inguinal, and 
axillary regions, and in the order named. 

Scars of the tongue would naturally lead to an inquiry as to 
the possibility of injury received during epileptic seizures. Irreg- 
ular scars at the angles of the mouth may indicate hereditary syph- 
ilis. 

The value of well-formed scars due to injury or to previous 
operative procedure, as indicative of such happenings, will at 
once suggest itself. 

THE VEINS 

Any unusual distention or overfilling of the superficial veins is 
easily distinguished. Such a condition may be local or general, 
and may be preceded, accompanied, or followed by edema, which, 
if marked, will mask the condition of the veins. While it is usual 
for edema to follow any considerable interference with a large 
vein, it does not always do so, for collateral circulation may be 
well established. 

General venous distention depends upon a hindrance to 
the flow of venous blood. Such a general stasis may be the direct 
result of cardiac weakness. Stasis in the pulmonary circulation 
may be somewhat overcome, if it depends upon left ventricle 
weakness, by an increased action of the right ventricle. Venous 
stasis from weakness of the right ventricle is not overcome, so 
that, as a consequence, there is a slowing of the whole blood- 
current. 

Diseases of the lungs or pressure upon one or more of the large 
vein trunks will cause venous stasis, and if there is increased 



HEAT AND MOISTURE OF THE SKIN 26 1 

intrathoracic pressure from any cause, or a lessened thoracic 
movement, then the heart receives a lessened flow of blood. 

General venous distention is best seen during convulsions and 
paroxysms of pertussis. 

Local venous distention usually depends upon pressure 
over a venous trunk of considerable size or with an important 
distribution. The cause of pressure should always be sought for. 



HEAT AND MOISTURE OF THE SKIN 

When the skin is abnormally dry, its nutrition is impaired, 
but in regard to the normal moisture of the skin there are marked 
individual differences. Under similar conditions, the skin of one 
child will be unusually active, while the skin of another will not be. 
Still, allowing for these individual traits, the activity of the skin 
has some diagnostic value. 

Increased Perspiration. — This occurs more or less during 
all fevers, but especially during the course of typhoid fever and 
tuberculosis, in the latter disease usually occurring most at night. 
General sweating is apt to be profuse during tetanus. Suddenly 
occurring and temporary sweating may attend the convalescence 
from all exhausting diseases and be induced by slight excitement 
or exercise. As an accompaniment of collapse, the sweat seems 
to stand out in big drops upon the forehead, and the whole surface 
of the body is bathed in cold perspiration. 

During the course of any febrile disease a sudden fall of the 
body-temperature is usually accompanied by a suddenly appearing 
sweat. General sweating, occurring when the temperature is 
normal or subnormal, indicates general weakness or debility. 
The sweating which indicates a septic condition appears suddenly 
with each fall in the temperature and disappears when the tem- 
perature begins to rise. Local sweating of the head is very sug- 
gestive of rachitis, and for a time may be the only sign to attract 
attention. Accompanying this there is usually baldness of the 
occiput. 

Diminished Perspiration. — This is the usual occurrence during 
the early stages of acute febrile conditions, and during the first 
davs of the acute infectious fevers this is a marked feature. Pro- 



262 THE CUTANEOUS SURFACE 

longed vomiting, diarrhea, or the occurrence of considerable 
edema predisposes to diminished perspiration. 

General Coldness. — This is usually associated with capillary 
circulation which is poor. It is seen in all forms of rigors and 
chills, and generally accompanies those conditions which cause 
cyanosis, so that the two are usually associated. It is one of the 
marked features of collapse, and may be present in conditions in 
which there is weakened heart action and no fever. 

Local Coldness. — This may be due to vasomotor spasm or to 
some obstruction to the local circulation. 

General Heat. — This may accompany any of the fevers, but 
is by no means a constant feature of such a condition. It is 
observed most typically in insolation. In susceptible infants 
a mild degree of general heat may be occasioned by the use of 
artificial heat. 

Local Heat. — This is one of the cardinal signs of inflammation. 
When temporary, it may be due to the influence of local applica- 
tions. 

LOCAL SWELLINGS 

The swelling due to edema has already been considered. Swell- 
ings which are due to the presence of tumors and accumulations 
of fluid are also considered elsewhere, so that it only remains for 
us to speak of three conditions — scleroderma, furunculosis, and 
warts. 

Scleroderma occasionally occurs during childhood and should 
not be confounded with sclerema neonatorum. The development 
of the disease is very slow. The lesions are local swelling and 
induration, with either a waxy pallor or dusky redness of the 
skin, but in either case the surface has a mottled appearance. 

The affected parts are hard and feel like tallow, but do not pit 
under pressure. Later in the disease atrophy occurs, and the 
skin then becomes tight and adherent to the subjacent structures. 
The temperature is usually subnormal. The affected parts may 
at times feel cold to the touch. The sclerosis may be band-like 
and limit motion to a considerable degree. 

Furunculosis. — Boils are common among ill-nourished chil- 
dren. There is one form which is peculiar to infancy in which 



EMPHYSEMA OF THE SKIN 263 

multiple boils appear upon any part of the body, but usually 
the scalp and neck. There are all sizes observed and they occur 
in crops. Usually there is but little pain and they have no core. 

Sporadic furuncle occurs as a local inflammation about a hair- 
follicle or gland of the skin. The affected part at first tingles, 
then a small, bright-red papule forms, which is followed by a 
hard, dusky red, pyogenic process, in the center of which is a core. 
When let alone, pus forms and usually there is spontaneous rup- 
ture. 

Warts (verruca) usually appear upon the hands and may be 
congenital or acquired. The growth is a hypertrophy of the 
papillae, covered with thickened epidermis. 

EMPHYSEMA OF THE SKIN 

This condition is due to the presence of air or gas in the subcu- 
taneous cellular tissue of the body. It might be mistaken for 
edema unless closely examined. Then it is found that there is 
no pitting upon pressure, but that the swelling yields readily, 
with a fine crackling sound. Its occurrence may be due to a 
wound which allows air to be admitted, or it may be occasioned 
by the rupture of a gas- or air-containing organ, or, again, from 
the presence in the tissues of organisms which are capable of 
producing gas. 

It is not unusual for such a swelling to spread from its original 
site and become more or less general. At best, it is a rare condi- 
tion, and its topographic occurrence is of no importance in diagno- 
sis. Without the definite history of an injury its occurrence is 
most common during the severe stage of pertussis. 



ANEMIA 

The present classifications of anemia are usually not definite 
scientific ones, as our present knowledge does not allow of such 
accurate classification. The difficulty has arisen chiefly because 
of our former disregard of the blood-changes which take place. 

There certainly can be no anemia without some change in the 
blood, so that the study of hematology is quite as important as 
a consideration of the clinical symptoms. Disturbances of cir- 
culation particularly lead to erroneous diagnoses, because such 
disturbances usually cause important symptoms, common also 
to abnormal blood-composition. These symptoms are chiefly pal- 
lor, small pulse with increased rapidity, weakness, and vertigo. 
Any or all of these may be present under the influence of fear or 
other nervous excitation, from masturbation, during the various 
heart affections, from overexertion, and in some of the acute 
affections of the stomach and intestines. 

The presence of anemia, then, is proved only when changes in 
the blood are proved. Such blood-change in anemia is not singu- 
lar, but there are several changes which take place. For the pur- 
poses of diagnosis it is only necessary to demonstrate one change, 
and that is deficiency in the hemoglobin. 

This deficiency may exist because too little is formed or because 
too much is destroyed. That the child is especially susceptible 
to changes in the blood is well established, for the entire devel- 
opmental period shows that a struggle is constantly going on to 
maintain blood equilibrium, so that, under apparently slight 
influences, anemia is induced. Undoubtedly much of this ten- 
dency is directly due to the fact that the blood of the infant and 
young child is low in hemoglobin and in specific gravity, and 
that the blood-cells are unstable, parting with their hemoglobin 
readily and upon slight provocation showing nucleated forms. 

Added to this is a constant and heavy demand for tissue growth, 
which works the blood-producing organs to their limit. Every 

264 



SIMPLE ANEMIA 265 

tissue in the child's body is really a blood-producer, but there are 
certain organs in which this is the chief function. 

We can readily understand that the pathology of the blood is 
very closely associated with that of every individual organ, for the 
blood gives and receives material from them all. The composition 
of the blood, therefore, depends in some measure upon the general 
condition of all of the organs of the body. 

Etiology. — Among the causes of anemia in childhood are: 

(a) Hemorrhage. — This may be the result of traumatism or 
occur during the course of some disease. If the hemorrhage is 
excessive (that is, nearly 50 per cent, of the total amount), the 
child dies with all of the symptoms of acute asphyxia. If the 
hemorrhage is moderate in amount, the fluid portion which is 
lost is replaced by fluid from the tissues and from the food. The 
corpuscles are replaced slowly by the tissues which form them. 
In the chronic forms of hemorrhage the blood returns to its normal 
condition more slowly, because the cause is usually still more or 
less active. 

(6) Toxic Elements. — Intoxications may follow the ingestion of 
certain drugs, or may accompany the acute infectious fevers, 
nutritional disorders, organic diseases, malignant neoplasms, etc. 



SIMPLE ANEMIA 

Extensive observation has demonstrated the fact that in most 
cases of anemia the normal mode of blood regeneration is pre- 
served; thus we class these as simple anemias. The causes may 
be an acute, a subacute, or a chronic condition following hem- 
orrhage. Any constitutional or organic disease may lead to 
the development of anemia, by interference with the keenness of 
the appetite, by loss of blood, by imperfect oxidation of the 
blood, and especially through the influence of albuminuria and of 
suppuration. Toxic elements also play an important part in 
the production of this form of anemia. But whatever the direct 
cause, the essential result is the same from all causes — change 
in the blood. 

The most important blood-change is the reduction in the 
hemoglobin, for this gives us positive evidence of anemia and 



266 ANEMIA 

also leads to a determination of its degree. In mild cases the 
corpuscles differ little, if any, from the normal, while in the more 
severe cases some deviations from the normal are noticeable, and 
this is true numerically as well as morphologically. Morphologic 
changes affect both the size and the shape of the corpuscle, the 
size being somewhat smaller than normal, and the shape somewhat 
distorted; this is called "poikilocytosis." 

Even in the mild cases the changes manifested by staining are 
usually pronounced. The appearance of normoblasts (nucleated 
blood-corpuscles of the same kind as those found in normal red 
bone-marrow, but now circulating in the blood) is not any indica- 
tion of the severity of the anemia, but they are usually rarer in 
the mild than in the severe forms. 

Of the characteristic clinical symptomatology of simple anemia, 
pallor of the skin and mucous membranes is the most prominent, 
as a rule. Such pallor is usually intensified by a permanent con- 
striction of the peripheral blood-vessels. It cannot be stated too 
forcibly, however, that in childhood pallor is by no means a con- 
stant feature of anemia, unless we simply consider pallor of the 
conjunctivae and the ears. Muscular weakness and sensations of 
weakness and fatigue upon slight exertion are due to the same 
cause as the pallor — deficient hemoglobin. 

According to the severity and chronicity of the anemia, the sev- 
eral organs of the body suffer in consequence of the reduced value 
of their nutrition, so that all of the physical and psychic functions 
are much below normal. Pallor is particularly marked in the mu- 
cosa of the mouth and the conjunctiva ; the sclerotics are pearly, 
the ears waxy, and the whole muscular system is atonic. 

The general metabolism is usually not reduced, so that when 
one finds, as is true in a few instances, that these functions are 
abnormal, one may conclude that it is not due to the anemia, but 
to some special cause. Bven in severe forms of anemia, the adipose 
tissue is well preserved, unless there is some complication of a nu- 
tritional nature. 

Conditions like the above readily account for the almost innu- 
merable symptoms which are traceable to their influence. The pulse 
is apt to be weak and irregular, and perhaps rapid. Vague pains 
in the limbs or in any part of the body may be complained of. Res- 



PERNICIOUS ANEMIA 267 

pirations are more shallow than usual and dyspnea is evident upon 
slight exertion. Vertigo and tinnitus aurium and syncope may 
occur. Digestive disturbances are very common and catarrhal 
inflammation £>i all kinds is frequent. Epistaxis, vesical irrita- 
bility, sphincter atony, and incontinence may occur. 

The diagnosis is made from the most manifest symptoms of pal- 
lor, muscular weakness, and dyspnea, substantiated by a blood ex- 
amination, or at least a test for hemoglobin. This latter procedure 
will serve also to distinguish a simple form of the disease from a 
progressive pernicious form. Blood analysis should be practised at 
intervals after the occurrence of any of the infectious fevers. 

Before the most prominent symptoms are present to a marked 
degree, the diagnosis of simple anemia can in a few instances be 
made (corroborated by blood examination) from the fact that the 
child's sleep is restless and that during the day mental torpidity 
is present to a greater or less degree. 



PERNICIOUS ANEMIA 

The pernicious form of anemia is not as rare as is commonly sup- 
posed. The apparent rarity is due to the fact that the number of 
cases reported is proportionately small, but when we come to con- 
sider the infrequency with which blood examinations are made 
in the anemias, we at once see that the proposition is not fairly 
stated. 

Pernicious anemia must be differentiated from all other forms by 
an examination of the blood, and such a distinction is very im- 
portant, because, in contradistinction to the mode of regeneration 
in simple anemia, in the pernicious type blood regeneration takes 
place in a way which is different from the physiologic. In the 
blood-forming organs (that is, those in which this function is the 
paramount one) and in the circulating blood we find cells which 
are never found in the healthy child. As these are found physio- 
logically in embryonic life, this is termed "reversion of blood for- 
mation to the embryonal type." 

Every known condition which lowers the vitality of the child 
may be reasonably assigned as a cause of pernicious anemia, so 
that there is no need of entering into a detailed account of these 



268 ANEMIA 

The symptoms are those of a general anemia. The pallor of the 
skin in this type is somewhat peculiar and yet very difficult of de- 
scription. It is somewhat of a lemon yellow or a faded yellow hue 
rather than a waxy color, and associated with it there is more or 
less edema in the face, abdomen, and legs. 

There is a very marked difference between the constitutional 
symptoms and the finely nourished appearance of the child. We 
encounter no disease in childhood in which such a marked cachexia 
exists with so little change in the adipose tissue. The whole mus- 
culature, however, is atonic. During the whole course of the dis- 
ease there is a transitory fever which persists for a short time only, 
so that it may go undiscovered unless the temperature is taken 
several times daily. 

Cardiac disturbances are apt to be most pronounced, and chiefly 
of palpation upon the slightest exertion, and this, in turn, may 
result in dyspnea and precordial distress. Heart auscultation 
shows over all of the valves (usually) clear, soft (usually systolic) 
murmurs. Percussion over the heart is normal. The pulse de- 
pends upon the condition of the heart, and is usually of low tension, 
frequent, and small. 

The digestive organs exhibit a variety of symptoms, but usually 
there are more or less vomiting and flatulence and a marked repug- 
nance to food, and especially to certain articles of diet. Outside 
of tiring quickly under the influence of exertion of the mental facul- 
ties, there are no characteristic symptoms referable to the nervous 
system, except one which may be prominent in older children — 
loss of memory. Retinal hemorrhages occasionally occur, but as 
they do also in simple anemia at times, there is no distinct value 
in finding them. They are rather an indication of the severity 
than of the form. 

Now a word as to paresthesia, ataxic symptoms, muscular inco- 
ordinations, atrophies, and pupillary rigidity; these are considered 
by many writers as part of the symptom-complex of the disease, 
but it is too early to so consider them. They are far from being 
constant, are independent of the severity, and seem to be an 
independent affection of the cord from toxins. 

Pernicious anemia runs a chronic course with remissions (of a 
few weeks) and covers a period of from three months to four years. 



LEUKEMIA 269 

Death generally occurs during the first year. The diagnosis is 
made by the blood-findings. In a fairly defined case staining 
shows that a majority of the erythrocytes have enlarged diameters 
and great richness in hemoglobin. Under repeated examinations 
megaloblasts are found, but in small numbers. Besides these we 
observe normoblasts and microblasts, also microcytes. In ad- 
dition, all other peculiarities of a simple anemia may be found. 
The red corpuscles are always reduced markedly in number; spe- 
cific gravity is lessened and the hemoglobin is reduced, but with 
a relatively high percentage. 

If the case is well developed, the diagnosis between the simple 
and pernicious types is not very difficult. The peculiar pallor, 
weakness, which is extreme, and yet with a well-developed adipose 
tissue deposit, the prominent heart signs, and the liability to diges- 
tive disorders, all give a picture which is most indicative of the per- 
nicious type. After some observation, if a remission occurs, we 
have added a valuable differential sign. 

But whether the symptoms are well developed or not, a blood 
examination must be made, and if in the blood there are found un- 
doubted megaloblasts and megalocytes predominating, the diagno- 
sis is fully established. If they are not found, the diagnosis be- 
comes much more difficult, and repeated examinations may have 
to be made. 

LEUKEMIA 

In this disease the numerical ratio between the red and the white 
cells is changed and, besides this, both show morphologic changes. 

The disease is very rare, may be congenital, or may begin at any 
time of life. The etiologic factors are not well marked. 

Usually there is an insidious onset, and generally when symp- 
toms are presented with any prominence they are the terminal 
ones. 

Hemorrhage, which may be either slight or abundant, from the 
nose, mouth, stomach, or the bowels, may be the first symptom to 
attract attention; then, with patient inquiry, we may obtain a 
history of some long-standing but indefinite indisposition which 
preceded it. A rise of temperature is not uncommon (101 to 
103 F.), and is preceded by vomiting or a convulsion. Anorexia 



2 70 ANEMIA 

is marked and diarrhea may be present. And so the list might be 
added to almost indefinitely; there is little that is characteristic. 

Among the more constant features we observe : (a) An abnormal 
amount of uric acid in the urine, (b) A tendency to bleeding from 
the mucous membranes and beneath the skin. 

The course of the disease is somewhat acute, with rapid emacia- 
tion, prostration, and progressive intensification of all of the symp- 
toms. With a less acute course death occurs from asthenia. The 
diagnosis rests entirely upon the findings in the blood: (a) De- 
creased red corpuscles ; (6) increase in the number of leukocytes ; 
(c) the presence of large multinuclear leukocytes, increased transi- 
tory cells, nucleated red blood-corpuscles, microcytosis, and poi- 
kilocytosis. 

CHLOROSIS 

This disease develops almost exclusively in young girls at the 
period of puberty. This practically removes such cases from the 
hands of the pediatrist, so that its consideration will be brief. The 
cause is not well understood. The blood-findings are lowered 
specific gravity, diminished erythrocytes, disproportionately di- 
minished hemoglobin, with the added feature of poikilocytosis 
and normoblasts in the severe cases. The symptoms are due prin- 
cipally to circulatory disturbances. The whole musculature ex- 
hibits the want of oxygen and the atony is marked. If the diagno- 
sis is based upon the whole clinical picture and the blood-findings, 
the chance of error is practically nil. 



EXAMINATION OF THE HEART 

The symptoms of disease affecting the heart are dependent upon 
its anatomic structure, its physiologic functions, and also upon the 
morbid process which may be present. The size of the organ in 
proportion to the body is somewhat larger in infancy. From 
birth until the third year the increase in the weight of the organ is 
rapid ; from the third until the seventh years the growth seems to be 
considerably less, and from the seventh to the eleventh years the 
change is scarcely noticeable. About the time of puberty there is 
a very rapid increase again. 

The difficulties which are offered by an examination of the heart 
in infants and young children are those of deduction and not those 
of method. There are present physiologic deviations from what 
we find in the adult heart, but these are pronounced and are easily 
remembered. The chief difficulty is in properly apportioning the 
value of each symptom in the young child. Under the age of two 
years the systolic murmur exceeds in strength to a considerable 
degree that of the diastolic, and while this holds true over the 
whole of the cardiac region, it is particularly marked at the apex. 

The second sound of the heart is loudest in the left second inter- 
costal space and is weakest in the region of the aorta. 

Position of the Apex-beat. — All that can be said about the 
position of the apex-beat in children must be of a somewhat general 
nature, for if one has taken the trouble to examine a large number 
of hearts, the fact is soon demonstrated that the position of the 
apex-beat is far from being a constant feature, differing not alone 
in different children, but in the same child at various periods. Fur- 
ther than this, this change follows no definite rule. When the ex- 
amination is made, the child should be in the sitting position and 
slightly bent forward. Generally speaking, the apex-beat is then 
found to be a little higher than in later life, the whole heart being 
somewhat higher in the chest, owing to the more elevated position 
which the diaphragm occupies at this period. 



272 



EXAMINATION OF THE HEART 



1 1 « 



The apex-beat is observed to be more to the left than in the adult, 
but if such a deviation exceeds one inch in a child whose chest is 
normal in size and shape, then such may be safely considered as 
abnormal. In the presence of deformity of the chest or any 
disease or condition which alters its normal proportions, the 
apex-beat is changed in its relative position to the anterior thor- 
acic wall. Less frequently in children than in adults a distention 
of the abdomen will alter the position of the apex-beat. 

Displacements of the 
Apex-beat. — In cardiac hy- 
pertrophy, and especially that 
of the left ventricle, there is a 
moderate degree of displace- 
ment of the apex-beat to the 
left. If the displacement is of 
a moderate degree to the right, 
it is suggestive of hypertrophy 
which affects the right ven- 
tricle mostly. When the dis- 
placement is more than mod- 
erate in degree and is very 
noticeable, then the indica- 
tions are different, and the 
cause is usually found to be 
some condition outside of the 
heart, and particularly of 
pleuritic effusion. 

Inspection. — For the pur- 
poses of diagnosis inspection 
is frequently made of the 
precordia, which is the portion of the chest which immediately 
overlies the heart. The child must be stripped and placed in a 
good light if any information is to be gained. 

Prominence of the precordia is observed sometimes in hyper- 
trophy of the heart, but is much more frequently seen in children 
who are rachitic or who have been subjects of that condition within 
a year or so. This must not be confounded with that promi- 
nence of the chest which is more general and which persists for 




Fig. 84. — Showing the marked change in 
the position of the apex-beat by change of pos- 
ture. The solid dot indicates the position of 
the apex-beat when the child is recumbent. 
The circle indicates its position when the child 
is lying upon the left side. The figures 4, 5, 
and 6 correspond to the ribs. 



PERCUSSION 



273 



life and is due to rachitis. When the precordia is sunken or de- 
pressed, the cause is in almost every instance an old rachitis. 

Palpation. — This is the method by which the apex-beat is lo- 
cated, for inspection is very unsatisfactory in childhood, and in 
infants the cardiac impulse is so weak and the infant chest so well 
covered with tissue that inspection is practically valueless in locat- 
ing the beat. The whole hand should be gently but firmly pressed 
over the precordia, then the finger may be placed at the point 
where the greatest impulse has been felt, and the apex-beat is dis- 
tinguished as a distinct thrust 
against the finger. The best 
position is the sitting one 
with a slight inclination for- 
ward, and in some instances 
a change of position will sup- 
ply more information. 

Percussion. — This must be 
very lightly performed or the 
result will prove of little value, 
for the chest wall is thin and 
very elastic in children. Now 
the chief difference in the re- 
sults of percussion in children 
is that the area of relative 
cardiac dullness is proportion- 
ately larger in them than in 
adults. 

The younger the child, the 
more wide-spread is this dull 
area, and if its normal limits 

are not remembered, it would readily lead one into the error of 
supposing that there was a degree of hypertrophy present. The 
area of absolute cardiac dullness is also relatively larger in the 
child than in the adult, although the shape of the area is about 
the same. A reference to the accompanying charts (Figs. 86, 
87, 88) will show the extent of these areas better than a detailed 
description could. 

At the age of one year the upper limit of the relative cardiac 




Fig. 85. — Lines of cardiac percussion. In 
the percussion of a child's heart it is well to fol- 
low some system, and the above diagram illus- 
trates one method. The lines of percussion are 
numbered in the order in which percussion 
should be carried out. 



2 74 



EXAMINATION OF THE HEART 



dullness is the cartilage of the second rib ; at six years this has low- 
ered its level to the second intercostal space, and at twelve years 
the limit is at the cartilage of the third rib. The margin at the 
right at one year is the right parasternal line (on a level with the 
nipple) ; at six years it is slightly more to the left, and at twelve 
years it is about midway between the parasternal line and the 
right border of the sternum. At one year, at six years, and at 
twelve years the left border of dullness is slightly beyond the 
apex-beat. 

The area of absolute dullness during the first twelve months is 
limited to the lower border of the third rib, and at six years there 

is a diminution, so that 



the area extends to the 
upper border of the 
fourth rib only, while at 
twelve years its limit is 
the lower border of the 
fourth rib. The right 
margin of absolute dull- 
ness is constant at all 
ages and is the left 
border of the sternum. 
The left border of dull- 
ness never quite reaches 
the mammillary line. 

Auscultation is of 
no practical value unless 
one succeeds in having 
the child remain quiet during the examination. On account of 
the thinness of the walls of the child's chest, all sounds are pro- 
portionately louder than they are in the adult, and as a natural 
consequence the area of diffusion is much greater. Just as in 
examining the chest, one is never certain of the exact spot 
examined when the unaided ear is used, an examination of the 
heart is never accurate without the use of the stethoscope. 

During the period of early infancy, at least, the differentiation 
of diastolic and presystolic murmurs is well-nigh impossible, on 
account of the normal rapidity of the heart's action at that time 




Fig. 86.— Relative cardiac dullness (outlined) and 
absolute cardiac dullness (shaded) areas in a child of 
six years. 



AUSCULTATION 



275 



of life. The rhythm and the frequency of the heart's action are 
both so easily disturbed in infancy that their significance is much 
less than in adults. 

Under conditions which are normal, the second sound of the 
heart is the weakest (at the aortic orifice) ; the loudest is the first 
sound at the apex. The accentuation is upon the first sound and 
not upon the second, as we observed in adult life. Reduplica- 
tion of the sounds of the heart is not infrequent, and it is due to 
the fact that the valves of both sides do not close at exactly the 
same moment. It is most marked under the influence of excite- 
ment. 

When a murmur is present, the question at once arises, "Is it 





Fig. 87. — Infant of one year of age. Fig. 88. — Child of twelve years of age. 

The areas of relative cardiac dullness (outlined) and of absolute cardiac dullness (shaded) in 

an infant of one year and a child of twelve years. 



from the heart, from the pericardium, or from the great vessels?" 
During the first three years of life systolic murmurs predominate 
to a very large degree; accidental murmurs are not common. 

If there exists a diffused dull sound of the heart and this is asso- 
ciated with an increase in the apex-beat, hypertrophy should be 
suspected. If, however, the apex-beat is materially weakened, 
then one of two conditions may cause it — fluid in the pericardial 
sac or dilatation of the heart. 

The former condition is rare in young children, is accompanied 
by more or less painfulness upon pressure over the precordia, and is 
associated with a friction rub. If hypertrophy exists and the 
sounds of the heart remain apparently unaltered, it is strongly 



276 EXAMINATION OF THE HEART 

suggestive of chronic nephritis, and the urine should be examined 
at once. 

Pericardial Murmur. — This is more of a cracking than a blow- 
ing sound and is heard over a limited area only. The friction rub 
may or may not be increased by change of position from the prone 
to the upright, but it usually is increased. Friction rub appears 
generally at the base and its occurrence is not connected with 
either systole or diastole. 

Acute Pericarditis. — This disease is rarely encountered before 
the third year of life, although after that time it is observed fre- 
quently in association with rheumatism, being one of the common 
fatal complications of that disease. Next in frequency it is second- 
ary to pleurisy or to pleuropneumonia, the acute infectious dis- 
eases (particularly scarlet fever), pyemia, tuberculosis, and local 
conditions (as traumatism, abscess, necrosis of neighboring struc- 
tures, etc.). 

In early infancy left-sided lesions of the lungs are the most com- 
mon causes, while pyemia holds second place. From six months 
until the third year the most frequent etiologic factors are bone 
disease and traumatism. During the third year tuberculosis looms 
up into prominence, and after that rheumatism is the great factor, 
with the acute infectious diseases second. It is important that 
these factors be remembered, for it leads one to an early diagnosis, 
which is of prime import. 

The results of a pericardial inflammation may be the production 
of serum, fibrin, pus, or blood, and these vary in different cases 
and, in fact, in different stages of the same attack. The effusion 
may be large or only slight. 

Before the seventh year the symptoms are anything but distinc- 
tive, and it is only by careful examination of the heart after the 
occurrence of one of the diseases which pericarditis usually follows 
that the diagnosis is made. There may be dyspnea, cyanosis, 
restlessness, or a slight temperature rise to arouse one's suspicion 
of the onset of the disease, and, upon the other hand, all of these 
may be entirely absent. 

Following a pneumonia or pleurisy, the only thing to lead one to 
suspect the disease may be a prolongation of the original disease, 
and then examination reveals that this depends upon the condition 



ACUTE PERICARDITIS 



277 



of the heart. If the disease is of the purulent form, then there are 
symptoms of septicemia, an irregular temperature, chills, profuse 
perspiration, and rapid and extreme prostration or collapse. 

In older children (that is, about seven years of age and over) the 
symptoms are more definite and the physical signs resemble quite 
closely the adult type. These include a double friction rub which 
appears early in the disease and lasts for a short time only (so that 
it is commonly overlooked). This is heard over a small area near 
the base, the sound is not transmitted, and there is no relation of 
the sound to respiratory movement. When effusion has occurred, 
then the position of the apex- 
beat is altered, it usually being 
displaced upward. In any 
event, it is more indistinct 
and may not be noticeable at 
all. 

There may be some bulging 
of the chest wall and an early 
edema is suggestive of puru- 
lent effusion. The normal 
area of cardiac dullness is in- 
creased in all directions. As 
effusion is absorbed, the fric- 
tion rub may return. An 
attack usually persists for two 
or three weeks, and may be 
followed by a subacute or 
chronic form of the disease. 

The difficulties of diagnosis are threefold in inf ancy : there is the 
rapid action of the heart, the remarkable compensatory powers, 
and the non-distinctive character of the symptoms. The acute 
dry form is so rare under the age of three that a diagnosis of that 
form must be made with great reserve. After the child has passed 
the age of three years, the diagnosis of pericarditis in the acute 
form is made by practically the same signs as in the adult, but the 
early recognition of the disease comes by a remembrance of the 
etiologic factors and a consequent frequent examination of the 
heart. 




Fig. 89, 



-Point at which pericardial friction is 
most often heard. 



2 7 8 



EXAMINATION OF THE HEART 



The diagnosis of pericardial effusion offers much difficulty be- 
cause of the similarity of dilatation. Dilatation is distinguished 
mostly by the pulsations of the heart being visible in wave-like 
undulations and the fact that it is a comparatively rare condition 
except under the influence of advanced valvular disease. 

From pleuritic effusions the distinction may be impossible, but 
the points to determine which help to favor the diagnosis of this 
condition are that the heart is displaced somewhat to the right 
while there is an uninterrupted dullness to the left; the heart 

sounds are not very feeble. 
Chronic Pericarditis. — 
This is more frequent than 
was formerly supposed and 
yet is not common in child- 
hood. It is found frequently 
at autopsy when no pericardial 
inflammation was suspected 
during life. It may follow 
successive acute attacks or the 
disease may be chronic from 
the start. This is the disease 
which, above all others, is 
treated as a functional heart 
trouble, for in most instances 
the symptoms can all be ex- 
plained upon that basis, if one 
is satisfied with the belief that 
functional heart disturbances 
are not the evidences of some 
disease which we are not capable of diagnosing at the present 
time and with present methods. 

When distinct signs are obtainable, there is usually a permanent 
extension of cardiac dullness, obscured heart sounds, and during 
systole a contraction of the chest over a small area close to the apex. 
This is followed by a diastolic impact or rebound which is best 
observed by palpation. A similar contraction may sometimes be 
seen in the infrascapular region in the tenth interspace on the left 
side (Broadbent's sign) and at times on the right side. The heart 




Fig. 90.— Hypertrophy of the left ventricle. 
Area of dullness in solid black. Normal area 
of absolute cardiac dullness lined. Apex is 
carried to the left and downward. 



ACUTE ENDOCARDITIS 279 

is enlarged, and because of this and the presence of murmurs val- 
vular disease is suspected. 

Acute Endocarditis. — This disease is very rare before the third 
year of life, but after the fifth year is not so uncommon. With our 
present knowledge it may be safely accepted that the disease is 
always secondary to some infectious organism. Two-thirds or 
even more of all of the cases are secondary to rheumatism, and in 
a large proportion of these the disease of the heart may be the only 
indication of the rheumatic condition. It is not uncommon to ob- 
serve chorea preceding or associated with endocarditis, and this 
may be without any evidence of articular symptoms. In a small 
proportion of instances the disease is secondary to one of the acute 
infectious diseases (particularly scarlet fever) or follows pneumonia 
or pleurisy. In a smaller number of cases it is secondary to bone 
disease, typhoid fever, and diphtheria. 

The onset of the disease, when it occurs as a manifestation of 
rheumatism, or independently of acute disorders, is rather abrupt, 
with severe general symptoms, as malaise, high temperature (103 
to 105 F.), marked prostration, restlessness (or stupor) , exaggerated 
heart action, and sometimes dyspnea and cyanosis. Usually the 
disease is not recognized even by these symptoms, but the case is 
diagnosed as one of tonsillitis, pharyngitis, acute indigestion, or 
some similar disease. 

An examination of the heart at frequent intervals would, of 
course, eliminate such errors. It is not until about the third or 
fourth day after the onset that one is able to obtain positive infor- 
mation which is sufficient for a diagnosis of endocarditis, and then 
there is obtained the characteristic soft, blowing, systolic murmur 
at the apex (see later). 

The usual duration is from two to seven days for the severe gen- 
eral symptoms, and for the whole attack from one week to three 
weeks. Then there may be a gradual subsidence of all symptoms 
(rare), the persistence of a murmur with subsequent typical signs 
of valvular disease (the usual course), subsequent dilatation of the 
heart, or repeated attacks. 

The diagnosis is frequently not made, and this is not because 
of much difficulty, but because the disease is not looked for and the 
heart is not examined. It is of the utmost importance that the 



28o 



EXAMINATION OF THE HEART 



heart be examined and reexamined under conditions in which 
there is the slightest ground for suspicion of rheumatism, and this 
is regardless of the fact of articular symptoms. 

Soft, Blowing, Systolic Murmur at the Apex. — This is gener- 
ally the first sign which we have of the existence of an acute endo- 
carditis. There is usually a transmission of the sound to the left, 
and later there are observed the evidences of dilatation or cardiac 
insufficiency. These positive signs are usually preceded by sus- 
picious ones, as exaggerated heart action, restlessness, and fever, 

occurring during the course of 
a rheumatic condition in the 
child, or more often occurring 
as the only manifestation of 
rheumatism. 

From endocarditis there 
must be a distinction made 
from pericarditis, and this is 
usually simple, for in the 
former the soft, blowing, single 
murmur at the apex is quite 
characteristic. It is dimin- 
ished by full inspiration also. 
Malignant Endocarditis. 
— This is rare in childhood 
and the symptoms are not 
suggestive and occur in such 
variety that the diagnosis is 
generally extremely difficult. 
The only symptoms which 
are at all indicative of the possibility of malignant endocarditis 
being their cause are the development of pyemic or typhoid 
symptoms with a petechial eruption in a child whose previous 
history is not suggestive of anything, but who has previously been 
a victim of valvular disease. The abrupt onset distinguishes it 
from typhoid in most cases very early. 

Chronic Valvular Disease. — The symptoms usually come on 
very insidiously, and, like most of the diseases of the heart in child- 
hood, the discovery of the condition is accidental. This can only 




Fig. 91. — Hypertrophy and dilatation of the 
right heart. Area of dullness in solid black. 
Area of normal absolute dullness lined. Apex 
is carried to the left, and note that dullness 
extends to the right of the sternum. 



CHRONIC VALVULAR DISEASE 28 1 

be so because we are neglectful in our examinations (or, rather, we 
do not make them) of the heart in children until some symptom 
definitely points to the heart as the cause of it. Instead of this, 
one who deals at all with the diseases of children should be con- 
stantly mindful of what etiologic factors are present and thus an 
earlier diagnosis would be made. There are naturally two rather 
well-marked divisions which are observed in chronic heart disease 




Fig. 92.— Hypertrophy and dilatation of both ventricles. Area of dullness in solid black. 
Normal area of absolute cardiac dullness lined. 



of the valves — the time when compensation is good and the time 
when it is poor or absent. 

Of the first stage (compensation good), only subjective symptoms 
are noticeable, and the chief of these is shortness of breath upon ex- 
ertion or excitement. Cough, epistaxis, palpitation, lip pallor, 
and headache are much less constant symptoms. 

The second stage (compensation poor or absent) usually follows 
some condition or disease which throws additional work upon the 



282 EXAMINATION OF THE HEART 

heart suddenly or for a protracted period, and among such factors 
are acute illnesses, puberty, unusual exertion, malnutrition, etc. 
The symptoms of this second stage are those of weakened heart 
action, with the veins overfilled and arteries underfilled. As might 
be expected, dropsy, beginning in the dependent parts (feet), is a 
usual accompaniment. Then follows a long train of symptoms: 
enlarged liver, enlarged spleen, dyspeptic symptoms of great 
variety, scanty and albuminous urine, dilatation of the superficial 
veins, clubbing of the fingers or toes, various cerebral symptoms, 
etc. 

Of the various clinical varieties, mention is made in detail, fol- 
lowing. 

Mitral Insufficiency. — This is generally due to attacks of acute 
endocarditis and is the commonest form of valvular disease in 
early life. There is systolic murmur, synchronous with the im- 
pulse of the apex and with the first sound of the heart, but it may 
also in part replace the second sound. It is heard with most in- 
tensity at the apex and is transmitted to the left. It may also 
be heard at the inferior angle of the left scapula. The murmur 
is very diffused. 

With only the foregoing data at hand, one is not sure that the 
murmur is not a so-called functional one, but in mitral insufficiency 
there is an accentuation of the pulmonic (second) sound heard at 
the left border of the sternum in the second space, and there are 
also signs of hypertrophy. If the last two are absent, then the 
diagnosis of mitral insufficiency must be guarded. Along with 
hypertrophy there is a carrying of the apex-beat downward and 
toward the left, and there may be some bulging of the chest wall. 
The heart sounds are loud and somewhat metallic. If dilatation 
is present, then the heart sounds are enfeebled and murmurs 
may even be lost entirely. The apex-beat is more readily made 
out and the area of cardiac dullness is increased. 

Mitral Stenosis. — There is a somewhat prolonged presystolic 
murmur, which is rough in its character, and terminating sharply 
with the first sound of the heart. It is loudest at the apex 
and is soon lost at a short distance from that point. There is a 
purring thrill which may be obtained by palpation, and which 
terminates suddenly as the impulse of the apex-beat is felt 



TRICUSPID STENOSIS 



283 



again at the chest wall, and such a thrill is equally valuable in 
diagnosis. 

Aortic Stenosis. — This gives a systolic murmur which is heard 
with greatest intensity at the right border of the sternum in the 
second space, and is from there transmitted upward distinctly to 
the carotids. The second heart sound is weak. There is an asso- 
ciated hypertrophy of the left ventricle, and if this is not present, 
then no positive diagnosis can 



be made from what we call a 
functional murmur. 

Aortic Insufficiency. — This 
is very rare in children. There 
is a prolonged diastolic murmur 
coincident with or substitut- 
ing the second sound. It is 
loudest at the left border of 
the sternum in the second 
space, and is transmitted down- 
ward to the apex. Associated 
with it there are marked heart 
hypertrophy and some dilata- 
tion (left ventricle), the hy- 
pertrophy being very notice- 
able during the time of good 
compensation, and the dilata- 
tion being most pronounced 
when compensation has failed. 




Fig- 93- — Large pericardial effusion. Area 
of dullness in solid black. Normal area of 
absolute cardiac dullness lined. 



If there is an intense throbbing of 
the carotids with sudden distention and then subsequent collapse 
of their walls, it is characteristic of aortic insufficiency. 

Tricuspid Insufficiency. — Systolic murmur is heard with great- 
est intensity over the lower portion of the sternum, and then over a 
limited and small area only. There is an associated dilatation of 
the right ventricle, the jugular veins are prominent, and there may 
be at times a decided systolic pulsation in them. 

Tricuspid stenosis, pulmonic stenosis, and pulmonic in- 
sufficiency are practically foreign to childhood (except as part of 
congenital disease). 

Functional Murmurs. — I deplore the necessity which compels 



284 



EXAMINATION OF THE HEART 



us to use the term functional, and am strongly of the belief that 
functional murmurs do not exist in fact. The capacity of the child 
to compensate is so large that a considerable amount of disease 
may be present without more than the slightest symptoms. With 
our present knowledge and methods we are compelled to continue 
the use of the term. In the recognition of such murmurs there 
must be repeated examinations of the heart and the elimination of 

any detectable change in the 
structure of the heart, and 
when this is determined, then 
there must be found an ade- 
quate cause for disturbance 
of the heart's action. 

Functional Heart Disease 
(or Disorder). — The same 
must be said of this as was 
said in regard to the existence 
of functional murmurs; simi- 
lar methods must also be 
followed in diagnosis (exclu- 
sion of all possibility of recog- 
nizable organic disease and the 
finding of an active cause). 
Such disturbances are unusual 
before the age of seven. The 
usual manifestations are pal- 
pitation, tachycardia, brady- 
cardia, and dizziness. The 
first and last mentioned are 
the most frequent. The at- 
tacks come on in paroxysms and last from a few minutes to a 
few hours. 

Venous Murmurs. — These are heard in the neck alone in some 
instances in which the child is in perfect health, and the limit of the 
area is the posterior border of the sternocleidomastoid, close to its 
clavicular attachment. If these murmurs are heard in any other 
situation, then they are strong presumptive evidence of anemia 
(see "Anemic Murmurs"). 




Fig. 94.— The diagnostic import of the 
location of friction fremitus. 1. Systolic 
aortic stenosis ; diastolic : aortic insufficiency. 
2. Systolic: pulmonary stenosis; diastolic: 
pulmonary regurgitation. 3. Systolic : tri- 
cuspid insufficiency ; hypertrophy and right 
ventricle dilatation. 4. Systolic : mitral insuf- 
ficiency, aortic stenosis, myocarditis. Presys- 
tolic : mitral stenosis ; aortic incompetency. 



CONGENITAL HEART DISEASE 285 

Anemic Murmurs. — These murmurs differ from the organic 
ones mainly in the fact that with them there are associated no other 
symptoms of heart disorder or disturbance. The murmurs are 
heard mostly at the base of the heart, on the left side, in the second 
space, or on the sternum itself, and are never loud. They are coin- 
cident with the systole invariably. Another characteristic is that 
they change from day to day, and this quality is even noticeable 
to a considerable degree at times under the influence of changed 
position. Sometimes they disappear entirely for a period. 

A very marked venous murmur may occur in anemic children 
and be heard below the clavicles on both sides of the chest, and as 
it increases under conditions which accelerate the flow of blood in 
the neck, it may be mistaken for an organic murmur. When re- 
peated examinations can be made, the inconstancy of such a mur- 
mur is soon evidenced, but when the diagnosis is desirable at once, 
the influence of change in the position of the head upon the mur- 
mur may be studied. In the venous murmur there is increase 
when the head is turned toward the side and decrease when the 
head is straight. 

Associated with anemic murmurs there is the general condition 
which causes them and its train of symptoms. 

Congenital Heart Disease. — This is in most instances due to 
malformation of the heart or to an anomalous disposition of the 
vessels. The defect or the combination of defects which may exist 
will not always show itself at birth or immediately afterward. 
Sometimes it is noticeable at once and is very evident, and, upon 
the other hand, there may be no suspicion of the trouble for one 
or even several months after birth. A much less number escape 
notice for a year or more, and more rarely still the period of puberty 
may be the time when the condition is first noted. 

Persistent cyanosis is in nearly every instance due to congenital 
heart disease, but its importance as a diagnostic sign to be looked 
for is very much overestimated. If cyanosis is persistent, it is a 
valuable indicator, but its absence proves nothing in regard to 
congenital heart disease. When present, cyanosis is more evident 
under the influence of such acts as crying, coughing, or, in fact, of 
any unusual exertion. It is much more constant in congenital 
heart than in the acquired forms of disease. 



286 



EXAMINATION OF THE HEART 



Murmurs are usually present, the most characteristic being a 
systolic murmur, which is most intense at the left base and very 
diffused. The kinds of murmur present are not of considerable 
diagnostic import ; the real value comes in their being loud. Loud 
diffused murmurs which are associated with cyanosis are almost 
invariably due to congenital heart disease, while loud apex mur- 
murs are indicative of the acquired forms. 

In congenital heart disease there is generally more or less en- 




Fig- 95- — Auscultation of the vessels of the neck. 



largement present (evidenced by dullness extending to the right 
of the sternum, with displaced apex-beat to the right), and there 
may be bulging over the precordia or at the lower end of the 
sternum. It is not always easy to decide that the case is one of 
congenital disease, for anemia offers some similarity at times. 
However, if the murmur exists alone and the child is anemic, the 
evidence is strong against congenital heart. As a result of congen- 



CONGENITAL HEART DISEASE 287 

ital heart the child is generally stunted in its growth and develop- 
ment, many of such children remaining rather puny and weak. 

For practical purposes it is not necessary to distinguish between 
the different types of lesions which are present. In most instances 
it is impossible to do so anyway, because of the prevalence of 
many lesions in one case, and the rapidity of the heart's action 
does not allow of a proper appreciation of the different sounds and 
conditions present. 



THE PULSE 

The pulse, like the respiration in childhood, is very variable, the 
slightest cause being at times sufficient to disturb both its fre- 
quency and rhythm. Whenever possible, the pulse should be 
taken during sleep, and for this it is not necessary to disturb the 
infant for if the wrist is not accessible, by a little practice one can 
just as readily gain whatever information is possible by placing 
the fingers upon the temples. 

When the frequency is great, then every second beat may be 
counted for a full minute and the result multiplied by two. 

Rate. — Shortly after birth the rate may vary from 120 to 140 a 
minute, but this is subject to considerable variation. During the 
first six months of life the average rate is 130; during the second 
six months, 1 10 ; during the second year, 100 ; from the third until 
the fifth year, 90; and from the fifth to the fourteenth year, 80. 

Increased Frequency. — Under certain conditions the cause 
of tachycardia is clear, as when it is due to drug action. Fever 
also increases the heart action, as the increased body- temperature 
stimulates the central endings of the accelerator nerves and the 
heart muscle itself. Uninfluenced by any other disturbing factor, 
the frequency of the pulse is proportionate to the increase in the 
temperature. This ratio, however, is disturbed in some diseases 
and is usually due to the action of toxins. 

In childhood increased frequency is in most instances due to 
the presence of fever or of prolonged crying. Either one of these 
causes may increase the rate in an infant from 40 to 60 a minute. 
Then there are several minor factors which do not act so decidedly : 
the time of the day (the rate is highest in the evening) , the season 
of the year (the pulse is more rapid in warm weather), exercise or 
play, the upright position, mental excitement, and pain. 

Much more important than any of these is the accelerative in- 
fluence of convalescence, general debility, anemia, and hemorrhage 
upon the rate of the pulse. Increased frequency accompanies all 

288 



FREQUENCY OF PULSE • 289 

of the valvular diseases of the heart. A frequent but feeble pulse 
indicates weakness of the heart's action, and if it occurs associated 
with coldness of the extremities and any cyanosis, these may be 
the only signs which we may have for a time in impending heart 
failure. 

It is just this character of a pulse which should be watched for, 
for weeks after an attack of diphtheria, because it will give us 
warning of threatened heart failure sometimes for days, and I be- 
lieve always for hours, before the event actually occurs. In scar- 
let fever the pulse-rate is characteristically rapid — more so than in 
any other disease with a similar elevation of temperature. 

Decreased Frequency. — This may be directly due to the use of 
certain drugs, especially opium, which is such a decided poison to 
infants and young children. Certain toxins circulating in the 
blood may produce a bradycardia. The pulse is relatively slow in 
typhoid fever. When the pulse is retarded and at the same time 
irregular, it is very suggestive of cerebral disease. In infancy this 
retardation may not be absolute; that is, we may observe a rise 
in the temperature which is not associated with a corresponding 
rise in the pulse-rate, although it is still irregular. 

Irregular. — The knowledge of the disturbances of rhythm is 
very limited, and the pulse is not an absolute guide to the heart's 
rhythm. A weak contraction of the heart may not give rise to an 
arterial pulse, and then again waves of different sizes may be sent 
at different speeds toward the periphery, so that the pulse cannot 
correctly interpret the rhythm. 

A slow, irregular pulse is always significant in childhood and 
should at once suggest the possibility of meningitis. On the other 
hand, a rapid and irregular pulse has no diagnostic value. Speak- 
ing generally, irregularity of the pulse in early childhood is of no 
moment unless associated with other qualities. It occurs under 
so many conditions, even being the rule in health, that the value 
of finding it is practically nil. 



19 



URINATION 

Dysuria. — Painful urination is very closely associated with re- 
tention of urine, and in some particulars it is quite impossible to 
clinically separate the two. When there is painful urination in a 
child, then there is more or less forced retention, and, on the other 
hand, when there is retention, pain is usually, although not always, 
present. 

Dysuria almost always points to some local condition, and the 
most frequent of these is as follows: 

In the newly born there is commonly noticed a sandy excretion 
upon the diaper after the act of urination, and the act is associated 
with evidences of considerable pain. This persists with every act 
of urination for a week or two ; rarely longer than that. 

In the newly born also another frequent cause is a prepuce which 
is adherent to itself or to the glans penis. The recognition of this 
condition is at once made upon examination. Sometimes when 
the attempt is made to draw back the foreskin, such resistance is 
met with that even the orifice of the urethra cannot be exposed. 
There are two active factors in this cause of dysuria — the mechan- 
ical obstruction itself and a reflex spasm of the sphincter of the 
bladder caused by the irritation of the retained smegma around 
the glans. In females the adherence of the labia will result in 
similar symptoms. More infrequently there are congenital de- 
fects of development, and particularly of the urethral mucosa. 

Pain of a burning character may be due to a too concentrated 
urine or overacidity of the same. The pain and distress which 
such a condition will cause in a child of a strongly neurotic tem- 
perament seem to be out of all proportion to the cause. The diag- 
nosis is quickly confirmed by an appropriate line of treatment. In 
case the treatment fails, then it is strong evidence that we are deal- 
ing with neuralgia of the pudendal nerves. The most intense of 
all dysurias are those which are due to vesical calculi. The stream 

290 



DYSURIA 291 

of urine is apt to be suddenly and repeatedly interrupted in its 
flow, and blood may be present in the urine. 

We will now consider some of the more frequent causes of dys- 
uria in detail. 

Calculi. — The stones which occur during childhood are com- 
posed mostly of urates and uric acid (amorphous and crystalline), 
but there may be an admixture with the triple phosphates and 
other salts. Calculi may be formed in the kidney, and when not 
too large, may be passed on down into the bladder. They may be 
single or multiple, irregularly shaped or rounded. Renal calculi 
are much more common during childhood than during adult life, 
and vesical calculi are about eighteen times as frequent in males as 
in females. That there is a hereditary tendency to the formation 
of stones has been clearly demonstrated. 

There are many symptoms which are highly suggestive of cal- 
culi, and these are : frequent urination, whether during the day or 
at night, sudden diminution or stoppage of the stream of urine dur- 
ing the act of urination, pain or discomfort in the region of the blad- 
der, especially under the influence of exercise, and straining dur- 
ing urination. Such symptoms, however, are merely suggestive, 
for they may be present in similar variety and degree in many 
other conditions. When these other conditions are reasonably 
eliminated, then the only means for a positive diagnosis is exami- 
nation with the sound. 

When a stone is being passed through the ureter, there is gener- 
ally marked paroxysmal pain which begins in the lumbar region 
and radiates toward the pubis. The testicle upon the correspond- 
ing side may be retracted. When the passage is accomplished, 
pain usually suddenly ceases. 

Instead of these symptoms one may observe that there is dull, 
persistent pain in the loins, radiating to various parts of the lower 
abdomen and thighs, and especially noticeable after exercise. 
Associated with these there are usually more or less disturbance in 
the quantity of urine voided (generally an alternating scantiness 
and excess) and some nausea or perhaps vomiting. These arc col- 
lectively strongly indicative of calculi in the pelvis of the kidney. 
When the stone is situated in the kidney, blood may be present in 



292 URINATION 

the urine in considerable amounts; but when in the bladder, 
hematuria is rare. 

The diagnosis must consider the possibility of the symptoms 
being due to cystitis. Bimanual examination will detect a stone 
of considerable size when it is in the bladder, but a negative result 
does not exclude calculi. Exploration by the sound gives the 
only positive means of diagnosis. 

Balanitis. — It is easy to see how an inflammation of the prepuce 
which causes that part to become swollen, edematous, red, and 
sometimes covered with pus would result in dysuria. And this is 
the situation in balanitis. Retraction of the foreskin is not possi- 
ble, and usually during the act of urination it balloons consider- 
ably. 

While no examination can be made of the parts on account of the 
tightness of the prepuce, the disease is evidenced by marginal red- 
ness with the appearance of pus at the opening. In this connec- 
tion it is very important to determine that the pus is not from the 
opening of the urethra, for in this latter case we are dealing with 
an entirely distinct condition. To determine this, and also for the 
application of proper treatment, it may be necessary to slit up the 
dorsum of the prepuce, so that the parts may be exposed. 

Urethritis. — This may be simple or specific; it is very impor- 
tant to determine which. 

The simple form is benign, and no matter how protracted its 
course, does not exhibit any sequelae. The inflammation is usually 
confined to the anterior portion of the urethra and the discharge 
of pus is slight. The pain during urination is usually not extreme. 

Gonorrheal urethritis is more common than the simple form and 
the usual cause is direct contagion. The symptoms resemble the 
adult type without the marked constitutional signs. When once 
suspected, an examination of the discharge should be made by the 
microscope, for the only positive means of diagnosis is the presence 
of the gonococcus. 

Vulvovaginitis. — This may be of simple or of specific form. 
The simple form may be a persistence of the normal secretion which 
is present at birth, but which, under the influences of malnutrition 
and uncleanliness, occasionally becomes purulent. It is much 
more common, however, after the period of infancy is past, and 



FREQUENT URINATION 293 

occurs mostly in anemic, poorly nourished girls. Sometimes it 
directly follows some acute infectious disease, particularly rubeola. 

Dysuria is usually the first thing complained of, and this is found 
to be associated with a discharge which is thin and yellowish-white 
in color. When the inflammation is more intense, the color may 
become a yellowish-green and the vulva, hymen, and vagina are 
intensely inflamed and somewhat swollen. There may be a fetid 
odor to the discharge. Sometimes it is so abundant that the parts 
are glued together and excoriations are common. The disease 
runs no definite course and there are no general symptoms. 

In the gonorrheal form there are generally some slight indef- 
inite symptoms (malaise, slight temperature rise, anorexia, fret- 
fulness, etc.) which precede the appearance of the local signs. Dys- 
uria is generally marked, and with its occurrence there is the pres- 
ence of a copious discharge of thick yellow pus (sometimes with 
a greenish tinge) which leaves a characteristic stiff stain upon the 
clothing. Erosions readily occur, so that there may be more or less 
bleeding. The child may experience some difficulty in locomotion, 
on account of the swelling and the excoriations. The diagnosis is 
made by an examination of the discharge, which shows the presence 
of the gonococcus. 

Erosions of the Prepuce and Glans; Erosions of the Labia; 
Herpes of the Vulva. — All of these conditions frequently cause 
an amount of dysuria which is not in proportion to the lesion. 
The suffering is sometimes extreme, and especially in nervous 
children. This results in enforced retention. If an erosion is 
situated just within the orifice of the urethra, the pain and the per- 
sistence are marked features. 



FREQUENT URINATION 

Many of the conditions which are associated with dysuria also 
result in frequent urination. One of the commonest causes of 
frequent urination is some abnormal condition of the urine ; it mav 
be too acid or too concentrated, or, again, it may contain some 
irritant substance. When the passage of a stone is taking place 
there is frequent and strong desire to void the urine, and the desire 
may continue even when the canal is occluded bv the stone. Very 



294 URINATION 

frequent urination, sometimes painful and sometimes not, accom- 
panies cystitis. It is one of the constant symptoms. 

Cystitis. — This disease is not uncommon in children, but is 
more frequent in the females. The most common cause is expo- 
sure to cold, but bacterial infection takes place readily. Any of 
the conditions which excite local congestion may result in the 
occurrence of the disease. The one constant symptom is the 
desire for frequent urination, and this is associated with ardor 
urinae and tenesmus. There may be some temperature rise, but 
the local symptoms are the only marked or definite ones. The 
urine in the beginning of the attack is high-colored, acid, and con- 
centrated, and may contain blood, pus, and mucus. Later the urine 
is generally strongly alkaline or it may be neutral, and has a no- 
ticeable ammoniacal odor. Naturally there is usually consider- 
able sediment in such urine, so that it may appear ropy. The 
diagnosis is simple when the urine is examined, and this also usu- 
ally reveals the cause. Cystoscopic examination is only available 
in older children. 

Vesical Spasm. — This is evidenced by frequent urination, 
which is sometimes accompanied with pain. No age is exempt, 
but most of the cases are noticed in children between the ages of 
two and seven. The only symptoms are the local ones of frequent 
urination, perhaps some pain, passage of small quantities of urine 
at a time, and sometimes ardor urinae. Blood is never present 
in the urine. 

RETENTION OF THE URINE 

Retention is distinguished from suppression (which is considered 
later) by the fact that the urine reaches the bladder but is 
there retained. When retention actually exists, the bladder is 
more or less distended and is usually easily palpated. Under a 
hasty examination such a condition may be mistaken for ascites, 
but with reasonable care this could not occur, for a well-defined 
tumor is mapped out, corresponding to the situation of a distended 
bladder. The tumor disappears completely by catheterization. 

It is a very easy matter to overlook the existence of a distended 
bladder, and especially during the course of typhoid fever and 
meningitis, and in these diseases particularly it should be watched 



SCANTY URINE 295 

for. Some children get into the bad habit of holding the urine 
as long as possible so as not to interfere with their play, and when 
the act is then undertaken, the atonic condition of the distended 
bladder causes a temporary retention. 

Fear of pain caused by the act of urination is a very common 
cause of retention in little children, and this is the reason why 
retention is so closely associated with dysuria. The same causes 
are, of course, operable in producing not only one but two condi- 
tions. Certain injuries to the spinal cord and all states of coma 
result in more or less retention. Complete retention may some- 
times be the result of malformation. 



ANURIA (SUPPRESSION OF URINE) 
Suppression of the urine is distinguished from mere retention 
by the fact that the urine never reaches the bladder. Total sup- 
pression in the newly born may be due to some serious organic 
lesion or to some malformation. The usual causes are occlusion 
of the ureters or the renal tubules, or an absence of the secreting 
structures, this coming through the influence of degenerative 
changes, inflammations, or from neoplastic growths. 

Pressure from tumors, twisting of the ureters, or even faulty 
anatomic relations may cause it. Uric acid infarctions in the 
kidneys may induce it. Such a condition, when it clears up, gives 
a very acid urine at first and the urine is filled with uric acid crys- 
tals. Renal disease is the commonest cause. 

The fact that anuria really exists is demonstrated by the use of 
the catheter, and the bladder is found to be empty. 



SCANTY URINE 

Scanty urine must be distinguished from suppression and reten- 
tion. The condition arises frequently under the influence of any 
condition which diverts the fluids of the bodv in some other direc- 
tion. So it is the common occurrence after severe vomiting from 
any cause, during diarrheal diseases, under the influence of fever, 
when the sweat-glands are especially active, and when the inges- 
tion of fluids has been lessened. Lowered blood-pressure from 



296 URINATION 

any cause predisposes to it. Many of the renal diseases induce it, 
especially the acute congestions, chronic congestions, acute degen- 
eration, and acute diffuse nephritis. 



INCONTINENCE OF URINE 

The loss of control over the escape of the urine, or an uncon- 
scious voiding of the urine, may be due to contraction of the mus- 
cular fibers of the bladder or to relaxed or paralyzed sphincters. 
Such conditions may exist on account of causes within the brain; 
as comas (especially epileptic), insolation, shock, and the typhoid 
state. On the other hand, there may be simply interference with 
conduction to or from the vesical centers, as in injuries to the 
spinal cord, either from trauma, disease, or toxins. 

Irrespective of these rarer causative conditions, incontinence 
occurs as a true neurosis in children, and is known as enuresis. 

Enuresis. — Before one can properly recognize the condition 
there are several etiologic factors which must be understood. Age 
acts as one factor, as the nervous system is in early life so unstable ; 
heredity acts by endowing the child with an irritable nervous sys- 
tem; chronic malnutrition occasions a malnourished state of the 
nerves, thereby increasing reflex irritability and decreasing inhib- 
itory control. 

With the foregoing predisposing factors operative, it only re- 
quires a slightly active cause to start trouble and to keep it going. 
It may be a too acid urine or a too concentrated one, an overdis- 
tended bladder, too free ingestion of fluids, phimosis, worms, vagi- 
nitis, anal fissure, and a hundred and one other things whose im- 
portance is so slight that it is scarcely worth mentioning them. I 
really do so simply to put an estimate upon their unimportance, 
for with their removal there is no clearing up of the trouble, unless 
they have been the cause, not of the enuresis, but of the irritable 
condition of the nervous system. 

The only symptom is bed-wetting, and this naturally takes place 
with most frequency during the first two hours of sleep, when un- 
consciousness is most profound and inhibitory control weakest. 
The voiding of the urine may occur several times during the night, 
but this is not the usual course. By the time the age of seven is 



DISEASES WITH DIMINISHED EXCRETION OF URINE 297 

reached, the nervous system is generally less susceptible to reflex 
influence, so that the child is spontaneously cured. Sometimes the 
incontinence is not alone at night, but is present during the day- 
time also, but this form of the trouble is somewhat unusual and 
extremely difficult to cure. 



DISEASES IN WHICH DIMINISHED EXCRETION OF URINE IS 

MARKED 

Diminished excretion of urine is one evidence of a low blood- 
pressure, and therefore it is expected to occur under any condi- 
tion in which the heart action is weak for a considerable period. 

There is marked diminution in the secretion of the urine, during 
the acute exacerbations which occur in chronic parenchymatous 
nephritis, but at all other times the amount of urine is increased. 

Anuria or suppression of urine is considered separately in this 
part (see page 295). 

A more or less marked diminution in the volume of voided urine 
is noticed under the following conditions: 

Acute Congestion of the Kidneys. — This disease may result 
from exposure to cold, to traumatism, from the ingestion of cer- 
tain drugs, or occur during the course of any of the acute infec- 
tious fevers. The urine is scanty in amount and of a high spe- 
cific gravity. It contains some albumin, red blood-cells, and per- 
haps some blood-casts. 

The associated general symptoms are usually more or less head- 
ache, slight lumbar pain or aching, and a general malaise. How- 
ever, any or all such symptoms may be absent. The condition 
generally clears up within a very few days, or it mav persist as the 
commencement of an acute nephritis. Owing to the inconstancv 
of the general symptoms a diagnosis is only made bv the evidences 
of diminished excretion of urine and the examination for the ab- 
normal constituents. 

Chronic Congestion of the Kidneys. — This depends for its 
existence upon an interference with the return circulation of the 
kidney. The general symptoms are largely those of the disease 
which produced the interference and was originally responsible 
for the congestion (cardiac disease, chronic bronchopneumonia, 



298 URINATION 

etc.), to which symptoms are added those of the congestion. The 
urine is scanty and of high specific gravity, containing some albu- 
min and casts in some cases. 

Acute Degeneration of the Kidneys. — This is rather a com- 
mon disease in infancy and also in later childhood. It occurs 
with almost uniform regularity during the course of scarlet fever, 
diphtheria, and acute pleuropneumonia, and is often present also 
during the course of diseases which are accompanied with a pro- 
longed high temperature. The amount of voided urine is very 
small. No other symptoms are noticeable except those of the 
primary disease and the presence of albuminuria. The urine may 
contain a few hyaline or granular casts. 

Acute Diffuse Nephritis. — This may occur as a primary disease, 
but in the great majority of instances it is secondary to some other 
process. It is the characteristic post-scarlatinal nephritis which 
occurs generally in the third or fourth week of that disease. The 
onset is somewhat gradual. In the bulk of the cases there is a mod- 
erate rise of temperature and the height of this initial fever is 
generally a safe guide to the severity of the disease. 

Dropsy is a constant and usually a more or less marked feature, 
appearing first in the face, then the feet and legs, before it becomes 
more general. The amount of urine is diminished and albumin 
is present in considerable quantities. The specific gravity is usu- 
ally low. There are generally a large number of casts present, also 
red blood-cells, leukocytes, and renal epithelium. Anemia is a 
late occurrence. 

The active symptoms of the disease persist for about two weeks, 
then there usually follows a gradual improvement. The period 
following this may be one of apparent health for a considerable 
length of time, but with the subsequent development of a chronic 
nephritis, which is usually not attributed in any way to the pre- 
ceding acute attack, but which should be. 



DISEASES IN WHICH THE EXCRETION OF URINE IS MARKEDLY 

INCREASED 

There are two diseases in which increased excretion of urine is 
very prominent ; these are chronic nephritis and diabetes insipidus. 



DISEASES WITH INCREASED EXCRETION OF URINE 299 

Chronic nephritis may develop very insidiously in the child, so 
that it is a long time before attention is attracted to it. The 
little one may simply show a lack of development for its age, rest- 
lessness, recurring headaches, and moderate edema, which have 
no apparent cause. These may persist for a few weeks and then 
subside, only to return again. When the history is taken, one 
finds that months or years before there has been an attack of acute 
nephritis, or that dropsy followed one of the acute infectious fevers. 
Age seems to be an important factor, for the occurrence of chronic 
nephritis is usual before the eighth year of life. 

There are two quite distinct types of the disease, and these are — 
with exudation and without exudation. 

Chronic Parenchymatous Nephritis (with Exudation). — 
This is the type of chronic nephritis which generally follows an 
acute attack. It follows either immediately or after the acute symp- 
toms have apparently entirely subsided for a considerable period. 
The urine is quite constantly filled with albumin and casts, and 
is increased somewhat in amount, unless an acute exacerbation 
is going on, and then there is a notable decrease. Edema is at 
times very marked and at other times is hardly noticeable. Ane- 
mia is an early accompaniment, and with it are associated nervous 
symptoms of varied kinds and degrees and digestive disturbances 
of great variety. 

Chronic Interstitial Nephritis (without Exudation). — It 
is in this type that the amount of urine is notably increased. The 
color is pale and the specific gravity is low, while albuminuria is 
infrequent. Dropsy is not common, and when it is present, is onlv 
so to a small degree. The result of the mildness of the symptoms 
at the onset is that the disease usually develops unnoticed. The 
marked nervous symptoms are generally the first thing to attract 
attention, and these usually appear abruptly. Intense headache 
and marked dyspnea are generally the predominating ones. High 
arterial tension and cardiac hypertrophy are constant features, 
and the disease, as a rule, ends in acute uremia. 

Diabetes Insipidus. — While this is always classed as a disease, 
we know practically nothing in regard to its etiology, and we are 
simply dealing with a persistent polyuria. While it is a very rare 
condition, still childhood is not exempt in any way and the disease 



300 URINATION 

may begin soon after birth. The quantity of urine which is voided 
varies from five to twenty or more pints in twenty-four hours, 
and the urine is of a pale color, of low specific gravity, usually of 
acid reaction, and containing no abnormal constituent. 

The onset may be sudden, but a gradual development is the rule, 
the first thing that is noticed being that urination is frequent at 
night. An intense thirst causes the child to ingest large quantities 
of fluid, but the amount of urine voided usually exceeds the amount 
of fluid ingested. At the same time restriction of the amount of 
ingested fluid diminishes the amount of voided urine. Usually 
quite early there are some nervous symptoms, as palpitation, ceph- 
alalgia, restlessness, and neuralgic pains of varying intensity. 

It is not for some weeks that the general health suffers to any con- 
siderable extent. When it does, anemias and general malnutri- 
tion are the most prominent disorders, and these are persistent. 
In infancy there is a consequent retardation of development. The 
occurrence of a pronounced anemia naturally brings with it all of 
the symptoms due to marked impoverishment of the blood. The 
skin is usually dry and hot and constipation is the rule, both of 
these being due to the excessive extraction of water. The appe- 
tite is immense, and the craving for solid food sometimes is about 
as imperative as the demand for fluids. The temperature is nor- 
mal or may be subnormal. The condition may continue for years. 

The diagnosis must be made from diabetes mellitus, for in many 
of the symptoms the two are similar ; but in diabetes mellitus the 
urine is of higher specific gravity and contains sugar. A more 
likely error would be in mistaking the condition for chronic ne- 
phritis without exudation. The distinction cannot be made by the 
presence of albumin in the urine, the existing nervous symptoms, 
or the polyuria, for all of the nervous symptoms may be similar, 
the polyuria is a feature of both, and albumin may be present tem- 
porarily in both conditions. There are, however, two quite con- 
stant features of chronic nephritis of the form mentioned, and 
these are not present in diabetes insipidus ; they are high arterial 
tension and hypertrophy of the left ventricle. It is well also to re- 
member some of the common factors which influence polyuria in 
health, as free ingestion of fluid, fright, and exposure to cold. 
Absorption of effusions, reflex irritations, and hysteria also in- 
crease urinary secretion. 



THE URINE 

The size and the development which the kidneys of the infant 
have attained by the time of birth would suggest that they had 
some previous function, and the finding in the liquor amnii of cer- 
tain constituents of the urine proves their activity, at least. 

Urine is normally in the bladder at the time of birth and should 
be voided within a few hours of birth. It is no unusual thing to 
find anxious mothers and apparently intelligent nurses insisting 
that the infant has not passed any urine and claiming that this 
occurs over a period of one or more days. One must be slow to 
accept the mere statement, for many times the amount passed 
is very small and is dried up on the napkin before its passage is 
discovered. The first urine voided is usually very pale (unless 
long retained) and of a low specific gravity. The amount passed 
in the first twenty-four hours is about one and one-half ounces, but 
with the ingestion of fluids the amount increases, until at the end 
of the first week it averages eight ounces, with somewhat wide 
variations which are normal. The act is performed usually ten 
or twelve times each twenty-four hours. At six months the 
amount voided is about fifteen ounces ; at two years, twenty-four, 
and at five years, thirty ounces. 

For purposes of examination the urine may be collected in male 
infants by the use of a condom fastened over the penis, and in fe- 
males by the use of a small cup or vessel. When only a small 
quantity is needed (as for the examination for albumin), a piece of 
absorbent cotton may be used. It happens at times that it is nec- 
essary to catheterize the infant, and in such cases a small catheter 
must be used (No. 6, American scale). 

Color. — This is much paler in early infancy than in later child- 
hood, although the amount may be small. It deepens when the 
urine is concentrated from any cause. Diseased conditions nat- 
urally influence the color. In fevers it is apt to become partic- 
ularly turbid, and in young children the color may be quite white. 
When there is pus present, the urine may become milky white. 

301 



302 THE URINE 

Reddish-brown or red urine indicates that blood is present, but 
hematuria must not be confounded with hemoglobinuria, which 
is simply due to the presence of blood-pigment. This latter may 
occur as the result of certain poisons, in the infectious diseases, 
in malarial fever, and also in a peculiar condition known as parox- 
ysmal hemoglobinuria. The color is usually greenish-yellow when 
bile is present, and under a good light the green tint seems to pre- 
dominate at the top of the vessel. Ingestion of phenol or salol 
may give a similar discoloration. 

Urine is pale when it is large in amount or quickly voided, and 
various things influence the quantity and the rapidity with which 
it is voided after reaching the bladder. 

Quantity. — The average amount voided at different ages has 
already been referred to, but pathologically it is increased in dia- 
betes insipidus and in chronic interstitial nephritis. There is a 
diminution during acute congestion, chronic congestion, acute 
degeneration of the kidneys, acute diffuse nephritis and also dur- 
ing exacerbations of chronic parenchymatous nephritis. 

Specific Gravity. — The color is generally an indicator of the 
specific gravity, pale urine being of low density and highly colored 
urine high. Density is increased when the amount of urine is 
scanty from any cause (sweating, fever, lack of water, diarrhea, 
etc.). Density is decreased when the secretion is in large amounts 
from any cause (copious drinking, external cold, etc.). 

Reaction. — The reaction of healthy urine is acid under normal 
conditions, but the diet influences this to a degree, as does also the 
ingestion of certain drugs. This reaction is usually strong dur- 
ing the first days of life, but remains weak throughout the rest 
oi infancy. 

Urinary Sediments. — A white, flocculent sediment, composed 
of mucus and epithelium, is present in nearly all urines after a few 
hours' standing, and in early infancy the amount of mucus is so 
large that the urine is normally turbid a few minutes after it is 
voided. 

A dense sediment of a brownish or red color may be due to the 
amorphous urates, and these are dissolved by the application of 
heat. The sediment of uric acid may resemble brown or red pep- 
per ; the test can be made by the suspected material being placed 



ALBUMINURIA 303 

in an evaporating dish with a few drops of nitric acid, and as heat 
is applied, the uric acid dissolves with effervescence. The heat is 
continued until the material is evaporated to dryness and then it 
is allowed to cool. If touched with strong ammonia, a character- 
istic blue or violet color is produced. Yellowish or white sedi- 
ment may be due to urate of sodium. White sediments are gen- 
erally due to phosphates or in some cases to uric acid. Yellowish- 
white sediment may also be due to the presence of pus. Choco- 
late brown or reddish sediment usually consists of blood. 

Odor. — The odor is intensified as the urine is concentrated, 
and under conditions which cause much concentration the odor 
may become very marked. The ingestion of certain drugs and 
some articles of diet impart characteristic odors to the urine. In 
cystitis the odor may be intensely ammoniacal, and when much 
pus is present, after standing the urine may have a putrid odor. 

So far, we have simply considered those appearances and con- 
ditions of the urine which are detectable without chemical exam- 
ination. 

Chemical examination of the urine is treated fully and ably 
by many works which deal with that subject exclusively, and as 
such examinations do not differ in any way in children from an 
examination of the urine of adults, it seems to me that it would 
be out of place and quite unnecessary to go into details of a sub- 
ject which is a study by itself. Reference will be made to some 
chemical processes later on, but there will be no attempt to go 
into details. 

ALBUMINURIA 

Accidental albuminuria is the term used to designate the pres- 
ence of albumin which has been added to the urine with blood, pus, 
blennorrheal discharge, leukorrheal discharge, lymph, and chyle. 
The use of the microscope at once detects the presence of these, 
but it in no way excludes the possibility of some of the albumin pres- 
ent being there because of some associated fault of the kidney. 
It is always possible that there may be an admixture of albumin 
from two sources, so that additional means must be taken to de- 
termine this fact. To obtain a urine which is free from the differ- 
ent materials mentioned, anv one of which may cause albumin 



304 THK URINE 

to be present in the urine, it may be necessary to resort to cathe- 
terization of the ureters, but, as a rule, this is not needful, bladder 
catheterization being all that is essential. 

In the light of our present knowledge it is exceedingly doubtful 
if the normal kidney, which is free from the disturbances from 
which it so often suffers, ever permits the appearance of albumin 
in the urine. True, there are frequently intervals in which albu- 
min does appear in the urine, and without any appreciable symp- 
toms of a general nature, and this by many writers is called ' 'phy- 
siologic albuminuria." But I see no good reason for calling some- 
thing "physiologic" because we do not understand its cause; in 
any event "functional" would be a better term, for that word 
better conveys the idea that the condition is not understood at all, 
while the other word conveys the idea that the condition must be 
expected, and therefore it conduces to a careless disregard for 
occasional albuminuria. 

Leaving out of consideration the appearance of albumin in the 
urine which has already been referred to as "accidental," I believe 
that one is always safe in assuming that the presence of albumin 
in the urine is always evidence of one of two things: (a) a path- 
ologic condition, or (6) a disturbance which acts upon the kidney 
itself. 

The so-called functional albuminuria occurs most frequently in 
those children who present functional derangements of the ner- 
vous system and of the vascular system. This is not true of all 
such cases, but it is of the large majority. Now, it is a question 
whether or not a perfectly healthy kidney would allow the pres- 
ence of albumin in the urine, even under the influence of vaso- 
motor disturbance. Until we have more light upon the subject 
I believe one is certainly justified in taking the stand that when- 
ever there is albumin in the urine of a child, there is a lesion of 
some part of the renal elements, which under the influence of 
vasomotor disturbance allows albumin to appear in an appre- 
ciable amount in the urine. 

There may be an entire absence of any other symptoms which 
would aid in the detection of any disease; such symptoms may 
be beyond detection by our present methods, but the failure to 
detect can never be recognized as a denial of existence. 



HEMATURIA 305 

Broadly viewed, the occurrence of albuminuria in a child does 
not indicate that there is anything more than a fault somewhere 
in the economy. What that fault is, must be determined by other 
means. Albuminuria alone means little; albuminuria associated 
with other symptoms of disease means much. 



HEMATURIA 

Hematuria must not be confounded with hemoglobinuria, which 
latter is due simply to the presence of blood-pigment in the urine, 
while hematuria is evidenced by the actual presence of blood in 
the urine. In slight hematuria the microscope alone reveals the 
blood-cells in the urine, but where the amount is considerable, the 
urine may have a reddish-brown or black color. If the blood is 
streaked through the urine, then the most probable source of the 
hemorrhage is the bladder or the urethra. If the hemorrhage is 
from any other point, the blood is thoroughly mixed with the 
urine or may form tube-casts. 

As it is very important to determine at once whether or not blood 
is actually present, the following test may be applied : Add to the 
urine one-fifth volume of glacial acetic acid and allow it to stand 
undisturbed for thirty minutes, at that time adding one-third vol- 
ume of sulphuric ether and allowing that to remain for another 
half-hour. Decant the ethereal extract into a small test-tube and 
add a few grains of aloin. Now, if an equal volume of hydrogen, 
peroxid be added, a cherry- red color is obtained if blood be present. 

Among the more common local causes of hematuria are trauma- 
tism (whether from a stone or other foreign body, catheterization, 
or external violence), new-growths, congestion and inflammation 
anywhere in the genito-urinary tract, and ruptured veins. The 
chief of the general causes are hemorrhagic disease of the newlv 
born, purpura, scorbutus, malaria, syphilis, tuberculosis, acute 
nephritis, and hemophilia. The use of certain drugs may cause it. 
as turpentine, cantharides, potassium chlorate, phenol, etc. 

If the blood is due to the presence of stone, the general condi- 
tion usually remains good unless suppuration occurs. The pain 
may be most severe and associated with a rise in the temperature 
at times. Bleeding is not extensive and is relieved by rest when 



306 THE URINE 

the stone is in the kidney. If in the bladder, there is frequent de- 
sire to urinate, with an involuntary arrest of the act, pain radiat- 
ing into the penis, and the blood appears at the end of the act of 
urination. 

Recurrent hematuria may mean that there is a calculus, uric- 
acid crystallization, carcinoma, or malaria. In carcinoma the 
hemorrhage is profuse and occurs late in the disease, so that usu- 
ally the diagnosis has already been made from other symptoms. 
Malarial hematuria shows a decided periodicity. 

In tuberculosis the amount of blood is very small, and if the kid- 
ney is affected, pus and the tubercle bacilli are also found in the 
urine with the blood. When there is tuberculosis of the bladder, 
the blood is bright red and appears very suddenly and the symptoms 
are those of cystitis, so that there can be no positive distinction 
until the tubercle bacilli are discovered in the urine. It is not un- 
common to encounter a very considerable hemorrhage in cases of 
acute nephritis, and especially when it follows scarlet fever. In 
cases in which a doubt as to the source and the cause exists, it may 
be necessary to use the cystoscope, urethral catheter, the x-ray, or 
even an exploratory incision. 



HEMOGLOBINURIA 

This is distinct from hematuria in that, instead of blood, only 
the blood-pigment appears in the urine. It occurs in a paroxysmal 
form in childhood and from an unknown cause, although many have 
been suspected (chiefly malaria, syphilis, exposure to sudden chill- 
ing of the body, and severe muscular exertion). It is associated 
with more or less fever (ioi° to 105 F.) which follows a chill or 
a convulsion. Pain and various paresthesias may be present. 
Enlargements of the liver and of the spleen are usually observed 
and there may be some jaundice. 

The chief subjective symptom is a more or less intense feeling 
of anxiety. Between the attacks there is nothing which indicates 
in any way the cause, the child being in apparent perfect health. 
Sometimes in the intervals between attacks there is albuminuria, 
and this may alternate with the hemoglobinuria. The urine passed 
is generally red or dark brown, and there are few, if any, blood- 



PYURIA 307 

cells. The course of the trouble is from a few hours to three or 
four days. Dilatation of the heart occurs occasionally. The car- 
diac dilatation, the fever, and the anxiety all suggest a toxic ele- 
ment. 

PYURIA 

Pus found in the urine may come from any part of the genito- 
urinary tract, but the most frequent source during childhood 
is the pelvis of the kidney. Next in frequency it comes from an 
outside source, as abscesses which open into some part of the tract. 
When abscess is the cause, there is generally a very sudden ap- 
pearance of a more or less large quantity of pus, which persists 
only a short time and gradually disappears altogether within a few 
days. If the abscess is an old one, the only thing which may be 
found will be granular or fatty detritus. Pus coming from the 
pelvis of the kidney will mean different things as the condition 
may be acute or chronic. If acute, then it is suggestive of pyelitis; 
if chronic, then it indicates either calculi or tuberculosis of the 
kidney. 

Pyelitis. — The symptoms in themselves are not suggestive 
enough to allow of a diagnosis without an examination of the urine. 
During and following one of the acute infectious diseases pyuria 
may be the only symptom which is present. Usually the attack 
begins suddenly with repeated chills, a high and fluctuating tem- 
perature, and diminished secretion of urine. Symptoms refera- 
ble to the nervous system are then rapidly added, and loss of weight 
is generally rapid. 

Up to this point many diseases will be suspected, but there is 
a marked obscurity about the symptoms which renders the possi- 
bility of the diagnosis of one of these unreasonable when the facts 
are well balanced. The examination of the urine reveals the pres- 
ence of pus. Then the question arises whether it comes from 
the kidney or from the bladder. Pus from the bladder is of rare 
occurrence among children, and if the source of such is an abscess, 
then we observe the local signs. 

If upon examination we find an acid urine containing large quan- 
tities of pus and moderate quantities of epithelial cells from the 
bladder, pelvis, and tubules of the kidneys, with perhaps a few 



308 THE URINE 

hyaline casts, and this is associated with chills and fluctuating tem- 
perature, the diagnosis of pyelitis is almost certain. When pye- 
litis is chronic, pyuria may be the only symptom for a long time, 
but later on there is usually a tumor due to the associated pyone- 
phrosis. One characteristic of the chronic form is the marked ten- 
dency to acute exacerbations. 

Tuberculosis of the Kidney. — This is immediately suggested 
by the existence of a chronic pyuria. It is a rare disease and one 
whose symptoms are so indefinite that they are overshadowed by 
the general symptoms of tuberculosis of which they are a part. 
The diagnosis is made when, in the presence of an unmistakable 
tuberculous infection in some part of the body, we find that there is 
pain in the region of the kidney and some pus in the urine. To 
make the diagnosis positive, it is necessary to examine the urine 
to detect the presence of the tubercle bacillus. 



ENLARGEMENT OF THE SCROTUM 

An enlargement of the scrotum may be due to one or both of 
two things — an increase in the contents or an increase in the thick- 
ness of the walls. 

Under perfectly normal conditions the skin of the scrotum is 
thin and tender, and because of the many folds, it has a corrugated 
appearance. Under the influence of edema and of inflammation, 
both of which cause more or less swelling, this corrugated appear- 
ance of the scrotum is lost. In edema the skin has a pale color, 
there is absence of pain, and upon pressure pitting is observed. 
The penis is also almost invariably involved in the process. 

Under the influence of an inflammation the skin becomes hot, 
dry, and reddened, and there is more or less pain present. The 
usual causes of such an inflammation are erysipelas and injury, 
the latter being the less frequent. If the scrotum is swollen, but 
the skin remains normal, then we are certain that the enlargement 
is due to an increase in the contents. 

At once the question will arise as to whether we -are dealing with 
an inguinal or a scrotal hernia, or with a swelling of the testicle. 
Hernia is usually easily reduced when the effort is made with the 
child in the prone position, and, further than that, the reduction 
generally takes place suddenly. On the other hand, hydrocele 
gives us an oval tumor with a smooth surface; it is fluctuating 
and irreducible. Orchitis is very rare in childhood. 

Hydrocele. — This consists of an accumulation of serum in some 
part of the serous pouch which is brought down by the testicle in 
its descent or may be (in infants) due to an incomplete closure of 
this pouch at some point where fluid accumulates. There are 
several varieties. 

Congenital hydrocele differs from the simple variety m that it 
is due to an anatomic defect. When the testicle passes into the 
scrotum, it carries with it a portion of the peritoneum which should 
normally be obliterated at its neck. The lower portion then forms 
the tunica vaginalis testis, making a double vesture for the testicle. 

309 



3IO ENLARGEMENT OF THE SCROTUM 

The testicle does not lie in the cavity, but external to it. If the 
neck of the sac remains open, the abdominal wall must be defec- 
tive at the internal abdominal ring, predisposing the child to con- 
genital inguinal hernia and also to a determination of the abdomi- 
nal serum to the bottom of the sac, thus forming a congenital 
hydrocele. Thus we commonly observe the two conditions 
associated. 

The diagnosis is easy. The fluid content is easily reducible into 
the abdomen, and in some cases this is accomplished by position 
alone, while in still others pressure is required. A valuable point 
to remember is that in either event the reduction is gradual and 
in marked contrast to the reduction of hernia, which is sudden 
and en masse. However, if the two be associated, then there 
is a sudden reduction of the hernia, with a gradual reduction of 
the hydrocele following. The tumor caused by hydrocele is trans- 
lucent. 

Encysted hydrocele of the cord may occur in the connective- 
tissue sheath or in a portion of the peritoneal elongation which has 
not been occluded. The size may be as large as a hen's egg or 
smaller, and such cysts are tense, oval, smooth, and slightly tender 
to pressure. Fluctuation is hard to determine on account of the 
tension. 

The cysts are generally found between the external ring and the 
testicle, or in the inguinal canal. The diagnosis must differen- 
tiate hernia, as the long axis of the cyst is parallel with the cord, 
but the tumor is irreducible. Undescended testicle would hardly 
be suggested, for an examination will reveal it in its proper place. 
Sometimes, it may be necessary to make an exploratory incision 
for positive diagnosis. 

Hydrocele of the cord is the rarest of all varieties, and in' this 
form the scrotum remains normal and the testicle is in proper 
position. The tumor is reducible, small, and entirely above the 
scrotum. It may fill the inguinal canal, but may be complicated 
with hernia, in which contingency the same methods of diagnosis 
are used as in the above-mentioned congenital form. 

Hydrocele occurring in females offers some difficulty in diag- 
nosis. Tumor of the labia majora, or tumor occurring in the in- 
guinal canal, is strongly suggestive of hydrocele, but the differen- 



ORCHITIS 3 1 1 

tiation must be made between inguinal hernia and also pudendal 
hernia. Absence of pain or of any of the signs of inflammation 
would serve to distinguish it from vulvovaginal cysts or abscess 
of Bartholin's gland. 

Orchitis. — As a primary disease this is very rare, and as a sec- 
ondary one to epididymitis is almost unheard of. The most com- 
mon cause is an attack of parotitis. The children who are most 
susceptible to orchitis during an attack of mumps are those who 
are approaching puberty. As a rule, but one organ is affected, 
and this occurs about six to eight days after the attack of mumps. 
The duration of the disease is from four days to two weeks. In- 
jury and acute infectious disease are rare causes of orchitis. 

If one discovers a small round tumor, which is about the size of 
a walnut, and is located in the inguinal canal, easily reduced, but 
reappearing under the influence of abdominal pressure or abdomi- 
nal muscular action, one may be dealing with either a hernia or 
an impacted testicle. The first point to be determined would be 
the presence or absence of the testicle in the scrotum on that side. 
Absence would at once suggest that the testicle was impacted. 
The only possible chance of error would be if dropsy was localized 
at that point from any cause; but, being somewhat scattered by 
pressure, its gradual return would at once help to distinguish it. 

Chronic enlargements of the scrotum are almost invariably tu- 
berculous or syphilitic. In both diseases the development is very 
slow, there is practically no pain during the development, there is 
an irregular surface, and there may be soft areas also. The differ- 
entiation must take into consideration the associated symptoms 
of the disease in other parts and the history of the child. 



HEADACHE 

Until the child reaches the age of five years it is not a simple mat- 
ter to recognize the existence of headache. In a measure this is 
true of all painful sensations, for the little one does not definitely 
locate the site of pain, but usually complains in a general way. 
Even in a child who talks well and is of average intelligence pain 
is not definitely located. 

Headache in children under five, despite its difficulty in recog- 
nition, is not of common occurrence, except in connection with 
diseases of the brain and meninges. Recognition of headache in 
the very young is possible only when it is very severe, and then 
the usual manifestations of its existence are pulling at the hair or 
the ears, with almost continuous rolling of the head from side to 
side and contraction of the muscles of the forehead. There are 
associated general restlessness and crying. 

In childhood the occurrence of headache is of far more impor- 
tance than a similar condition in adult life, and the only safe way 
of dealing with it is as an important symptom whose cause must 
be satisfactorily explained before it is dismissed. If this symp- 
tom is treated lightly, it will lead one into serious error, and the 
younger the child, the more forcibly this applies. 

For diagnosis, headaches may be divided into those which are 
acute and those which are chronic ; this division will be followed. 



ACUTE HEADACHES 

The acute headaches of children are almost always associated 
with a rise in the temperature, and the first thing that must be 
determined is to what extent the headache is due to that rise of 
temperature. This is decided by the intensity of the fever and 
the character of the headache. 

In regard to the intensity of the fever, headache is very rare 
when the temperature is under 103 F. unless there is disease of the 
brain or the meninges present, and then it may be intense, with a 

312 



ACUTE HEADACHES 313 

lower temperature. The character of the headache is such when 
due to a rise in temperature that it is readily relieved by pressure 
over the temples, by the application of cold, by massage of the 
veins of the neck, and is increased for a while by active motion. It 
is true of all febrile conditions in children that they are usually as- 
sociated with headache of a more or less moderate degree. 

In determining the existence of headache it is necessary to elim- 
inate tenderness of the scalp which simulates headache. It is 
not uncommon to find that the scalp is the site of one or more cir- 
cumscribed foci of inflammation, and these cause pain. Then, 
again, but not so commonly, rheumatism shows most of its mani- 
festations of a painful nature in the aponeurosis of the scalp, and 
the child complains as of headache. Palpation soon discloses the 
presence of either of these conditions. 

Toxic Headache. — These acute headaches are due to absorp- 
tion of toxins from the alimentary tract, and are usually brought 
about by constipation or overfeeding or may be due to the toxins 
of the infectious diseases. If an acute headache occurs in a child 
who is already the victim of kidney lesion, it should at once excite 
suspicion of uremia, and this must be regardless of the fact as to 
whether there is fever present or not. 

Tuberculous Meningitis. — The headache of tuberculous men- 
ingitis is usually continuous and very severe, and bears absolutely 
no relation to the intensity of the fever, which is usually low. Gen- 
erally speaking, the greater the disproportion between the rise of 
temperature and the intensity of the headache, the more indica- 
tive it is of meningitis. There is a reason for this, for the common- 
est form of meningitis in childhood is the tuberculous, and one of 
the chief features of the disease is the low temperature range. 

Purulent Meningitis. — If the child is affected with a purulent 
meningitis, the temperature runs high, but this form is com- 
paratively rare in childhood, and when it occurs, the cerebral symp- 
toms are usually so marked that they rapidly aid in clearing up the 
diagnosis. The same might be said of cerebrospinal meningitis. 

Simple Meningitis. — The headache is usually very severe and 
continuous, just as in the tuberculous form of the disease, but the 
temperature is higher and the onset of the disease much more ab- 



3H 



HEADACHE 



rupt, so that headache appears early as a symptom, and generally 
within twenty-four hours of the onset headache is severe. 

Headache due to Disease of Organs of Special Sense. — In 
the ears there may be the presence of foreign bodies or of acute 
ostitis. The eyes may be the site of an acute conjunctivitis, or 
keratitis, iritis, or acute strain may be the cause. In the nose there 

Anemia 

Epilepsy 

Meningitis 

Anemia 
Autointoxication 
Eye-strain 
Syphilitic nodes f ^E^""^ \ >— j f Caries of the teeth 

Disease and foreign Hl— «^^ 1 f JhI 1 j ° titis media 

bodies in the I ■^^^ I 1 Foreign body 

nasopharynx J ■ 



Meningitis 
Epilepsy 
-j Spinal caries of 
cervical region 
Middle-ear disease 




Fig. 96.— Diagnostic significance of the site of headache in children. 

may be rhinitis or foreign bodies. Catarrhal inflammation of the 
frontal sinuses usually causes acute headache which is severe. 
There may be little or no elevation in the temperature and the 
child is not visibly ill, but the headache is marked. The presence 
of "snuffles" may be the only thing to attract attention to the 
nose. 



CHRONIC HEADACHES 
By the term chronic in this connection I do not mean to imply 
that the headache is continuous over a long period only, but include 
all such headaches as are prolonged and recur, as well as those 
which are transient in their course but recur from time to time. 



CHRONIC HEADACHES 315 

Chronic Headache due to Disease of Organs of Special 
Sense. — In the ears there may be impacted foreign body or chronic 
ostitis. The eyes may be the cause of the headache, being the 
site of muscular weakness, strabismus, errors of refraction, kerati- 
tis, or iritis. In the nasal passages there may be impacted foreign 
body, polypi, hypertrophic rhinitis, or adenoid vegetations. 

Tumors of the Brain. — These are not rare in early life, but the 
etiology is obscure when we leave out of consideration injury and 
tuberculosis. Of all the symptoms, headache is usually the most 
prominent, being persistent, generally very severe, and may be 
intense. Not uncommonly it occurs with most marked intensity 
during the night and in the early morning. 

Closely associated with the headache there are vomiting and 
vertigo. The result is that for a short time these cases may simu- 
late headache from disordered stomach. The vomiting, however, 
is of the projectile type, and shows no regard for occurrence in re- 
lation to meals. Like the headache, the vomiting and vertigo are 
persistent, making in all three very suggestive symptoms. 

In about four-fifths of all of the cases optic neuritis accompanies 
cerebral tumor. The ophthalmoscope is necessary for recogni- 
tion of this. In an early stage of the disease general convulsions 
are common, but there are usually long periods between the oc- 
currence of convulsions at first. This leads to a belief that the 
seizures are due to other causes. All degrees of convulsions are 
observed, from simple twitchings to severe and typical epileptiform 
seizures. Localized spasms commonly precede the onset of gen- 
eral convulsions. 

The mental symptoms show the greatest variety and complex- 
ity, and such symptoms are so frequent in childhood in the course of 
disease that they are not apt to excite suspicion for a considerable 
time. However, any child who exhibits headache associated 
with vomiting and vertigo, all of which are persistent (even though 
not at first severe), and at the same time is persistently and in- 
creasingly somnolent, must at once be regarded with suspicion. 

Sometimes somnolence is not present, however, until near the end, 
but there are still three characteristic symptoms — persistent head- 
ache, vomiting without apparent cause, and optic neuritis. If the 
vomiting is absent, as is sometimes the case, then optic neuritis is 



316 HEADACHE 

absent also, so that the most constant feature is headache, and if 
this is alone present, then there is considerable difficulty in the 
diagnosis at this stage of the disease. The only thing which ap- 
pears to affect the severity of the headache is the occurrence of 
hydrocephalus, and when this is well developed, the pain may 
disappear entirely. 

Nystagmus may occur with a tumor in any situation, but is most 
common late in the disease. Hydrocephalus also may occur with 
a tumor in any situation, but if early and severe, it indicates that 
the lesion is obstructing the sylvian aqueduct or the fourth ven- 
tricle. 

Local Symptoms . — It is not uncommon to observe a lesion 
of the frontal lobe without obvious signs. At other times there 
is some degree of mental impairment, which may be slight or 
amount to imbecility. When severe, the lesion is usually found to 
be bilateral. 

Inability to write indicates involvement of the left second fron- 
tal convolution and motor aphasia of the third frontal gyrus. Sud- 
den loss of consciousness or impairment of it, associated with 
automatism, is characteristic (may occur also in temporal and oc- 
cipital lesions). From pressure of the tumor there may occur 
brachial, facial, or crural monoplegia, or even hemiplegia which 
occurs gradually. There may be unilateral or bilateral anosmia. 
Blindness is not uncommon. 

If there are lesions which are destructive to the central convo- 
lutions, then we observe paralysis of voluntary motion in the cor- 
responding parts of the body, or there may be simply a marked 
weakness. Inability to localize touch and irritative phenomena are 
quite common. Localized epilepsy is among one of the early symp- 
toms, but rapid spreading of the same is frequent, so that Jack- 
sonian convulsions may involve the whole of one side of the body. 

Of the occipital lobe, the most characteristic local sign of tumor 
is homonymous hemianopia. There may be sensory epilepsy, vis- 
ual hallucinations, and visual aura. Of the temporal lobe, there 
may be mental alteration without other symptoms. When other 
signs occur, they are deafness, word-blindness, word-deafness, or 
total loss of speech. Hallucinations of smell and taste are common, 
but not their loss. 



CHRONIC HEADACHES 317 

When the internal capsule is involved, the chief local signs are 
hemiplegia, hemianesthesia which is never absolute, and hemian- 
opia. Tumor of the pons varolii presents the unusual combination 
of hemiplegia with crossed facial anesthesia. Ataxia is common, 
as is also intention tremor. Spastic paralysis of the face may oc- 
cur, also deafness and hemianesthesia. 

Affection of the medulla exhibits atrophic paralysis of the lips, 
tongue, palate, pharynx, and larynx. But lesions in this situa- 
tion are usually early fatal, so that they are not observed to any 
extent. The signs of cerebellar involvement are mostly dynamic, 
and to be well demonstrated the general mental and physical con- 
dition of the child must be reasonably good. 

Hemiataxia (on side with lesion) is frequent, being more pro- 
nounced in the upper than in the lower limb. Movement is uncer- 
tain and unsteady when attempt is made at finer adjustments. 
In about three-fourths of the cases the head is inclined to the shoul- 
der of the same side as the lesion, the face being turned slightly to 
the opposite side. This is noticeable most in the sitting position. 
When standing, the body is bent toward the side of the lesion and 
there may be a tendency to fall that way, for the child is very un- 
steady. While walking, the child does so with a lunge and tends 
to progress in a curved line. Sometimes there is a bilateral ataxia 
with a forward bending of the body, or there may be retraction of 
the head with backward inclination of the body. Nystagmus is 
generally marked, and irritative phenomena are sometimes very 
prominent. 

There has been no attempt to do more than suggest some of the 
more prominent of the many local signs of tumor in different parts, 
and for a complete description of detail reference must be made to 
some of the works upon that special subject. 

The diagnosis is at times difficult, and for a period may be im- 
possible. When optic neuritis exists alone or is associated with 
headache and vomiting, it at once leads to a suspicion of organic 
disease of the brain, or of kidney disease, lead poisoning, or anemia. 

The last two are usually easily eliminated, for there is a history of 
lead colic and the presence of the lead line in the one, and in the 
other the impoverishment of the blood must be very marked to 
cause such symptoms. Also in anemia the neuritis is of rapid 



318 HEADACHE 

development compared with that of tumor, and the influence of 
treatment is quickly apparent. In kidney lesions, there is the pres- 
ence of albumin in the urine, the headache is not so intense or so 
constant, and there is an entire absence of the focal symptoms. 

If basilar meningitis is slowly developed, it may simulate cere- 
bral tumor, but in the latter there is an absence of fever, of the slow 
and retarded pulse, of constipation, of retracted abdomen, and the 
pupillary changes. The onset of tuberculous meningitis is more 
rapid than that of tumor, and the prodromes, the wasting, and the 
history are all sufficiently marked to make the distinction soon 
clear. 

In some instances the symptoms of a slow onset of local signs 
with a progressive course are not due to tumor (although they 
markedly resemble such) , but are occasioned by an enlarging focus 
of disseminated sclerosis involving one of the peduncles of the cere- 
bellum. In these cases the optic discs are pale and the other symp- 
toms appear finally, although they may be long delayed. Hem- 
orrhage could hardly be mistaken, for the onset is so sudden, and, 
in marked contrast to tumor, the symptoms show progressive im- 
provement instead of becoming progressively worse. 

Cerebral Abscess. — This disease has much in the line of symp- 
toms which is similar to cerebral tumor, but not with the same 
severity. A rare condition at best, it is usually diagnosed at the 
autopsy table — not before. Abscesses are generally secondary 
(probably always so), and the conditions which are most liable to 
cause them are disease of the middle ear, traumatism, caries of the 
cranial bones, and suppuration in any part of the body. 

The first symptoms are usually masked, so that they are con- 
sidered as a part of the original disease which is present. Know- 
ing this fact, one should be suspicious when the symptoms of chills, 
headache, vertigo, and vomiting occur during the course of a dis- 
ease which might lead to the formation of brain abscess. They 
should be explained upon other grounds before we can feel at ease. 
Such symptoms may persist for one or two weeks, all the time in- 
creasing and terminating in death. 

Or, on the other hand, they may remain acute for a short time 
and then subside (this is the usual course, and the one which leads 
to so much error), so that for months there is nothing noticeable 



CHRONIC HEADACHES 319 

except occasional headache, vertigo, or nausea. Then, like light- 
ning out of a clear sky, acute symptoms occur of an acute menin- 
gitis or sudden coma, which prove fatal within a very short time. 
Then, when the autopsy is performed, there is found an encysted 
abscess which has ruptured. 

It is the associated meningitis which is so common which makes 
the diagnosis of abscess so difficult, and the youth of the child adds 
obscurity to all but the motor symptoms. If a sufficient etiologic 
factor is present and there occur headache, vertigo, and vomiting 
which are recurrent, it is suggestive ; and if there are added to these 
Jacksonian epilepsy seizures and focal signs, the evidence is still 
stronger. 

Migraine. — This autointoxication or intestinal intoxication 
finds its chief expression in paroxysmal headache. There are 
many predisposing causes, as the age (late childhood), constipation, 
poor surroundings, excessive feeding, etc., but far and beyond any 
of these is the marked influence of heredity. 

This predisposition is at once noticeable, and the family history 
is plainly neurotic, with rheumatism and neuralgic conditions pre- 
dominating. With the predisposition it requires but a slightly 
active cause to bring about an attack, so that if one attempted to 
enumerate the active causes, they would constitute a legion. Any 
condition, no matter how it is brought about, or at what time, 
which acts as a temporary cause of innervation, may bring on an 
attack. 

There is no question but that among the active causes, just as 
among the predisposing causes, one stands out prominently — liver 
incompetency. There may be the occurrence of certain pro- 
dromes, and when this is the case, the child is usually aware that an 
attack is about to occur. These are varied, but the most common 
are vertigo, ringing in the ears, spots before the eyes, and giddiness. 
Such may occur a few minutes or a few hours before the onset of 
the characteristic headache, which is unilateral and of rapidly in- 
creasing intensity. The pain is throbbing in character and intense, 
continuing, as a rule, for several hours. It is increased by mo- 
tion and by light, so that the child naturally seeks a darkened place 
in which to lie down. 

Nausea occurs usually quite early in the attack and increases 



320 PARESTHESIA 

in its intensity until vomiting occurs, and with this last event the 
paroxysm is terminated for the time being. After the vomiting 
the child generally sleeps, and awakens refreshed and apparently 
perfectly well. At times the headache and the nausea and vomit- 
ing are all mild, and the sleep which follows the attack is the prom- 
inent symptom, being so profound that it almost resembles coma. 
When this occurs, the mental condition usually remains somewhat 
sluggish for twenty-four hours, but not longer than that. 

The temperature throughout remains normal or nearly so. The 
duration of the attacks is a few hours to two days — rarely longer. 
The intervals between the paroxysms vary, but the average is of 
one month. The paroxysms do not repeat themselves upon suc- 
cessive days, so that such a history would at once be against mi- 
graine as the cause of the headache. The chief characteristics are 
the paroxysmal occurrence of headache, the marked hereditary 
influence in its production, and the unilateral situation of the pain. 

In the diagnosis from other forms of paroxysmal headache an 
examination of the urine is important. It is high-colored, with 
a high specific gravity and with an excess of uric acid, the purin 
bodies, and the xanthin bases. As the condition becomes more 
and more chronic the typical character of the symptoms may be- 
come diminished, but the history of previous typical attacks leaves 
practically no chance for an error in the diagnosis. The closest 
similarity is exhibited by neuralgia of the supra-orbital nerve (see 
below) . 

Neuralgia of the Supra-orbital Nerve. — The pain in this con- 
dition is very similar in character and location to that of mi- 
graine, but as the paroxysms are in nearly every instance due to 
malarial infection, they are periodical. When vomiting occurs, 
it is usually at the onset and not at the termination of the attack. 
Pressure over the nerve increases the pain, so that the condition 
is easy of recognition. 

PARESTHESIA 

This is a perversion of normal sensation. Visceral paresthesia 
is an abnormal sensation which is referred to some viscus and is 
not a mere diminution or excess of the normal sensations. The 
sensations referred to are not in any way limited in number or 



VERTIGO 32 1 

variety, but the more common ones are those of heat and cold, 
itching, burning, tingling, and numbness. Paresthesia is almost 
entirely limited in its occurrence to children who are in a chronic 
state of malnutrition, and in them it is not infrequent. 

When it is referred to as a more or less general sensation, without 
definite localization, or when it is constantly changing in its 
situation, it is merely indicative of the general poor condition of 
the child and of blood impoverishment. On the other hand, if 
it be definitely localized and persistent in its nature, it becomes 
of some definite diagnostic value, indicating some disturbance of 
the nerves which supply the affected area. 



VERTIGO 

This is a disordered condition of the sense of equilibrium, 
giving rise to a feeling of unsteadiness and the sensation of an 
apparent movement of the body itself or of surrounding objects. 
In childhood it is closely associated with disorders of the stomach, 
ear, and eye, and in the order named as to frequency. The condi- 
tion ought not to be considered lightly, but the cause must be 
sought for and eliminated if possible. 

It will be necessary to reassure the parents that the condition 
is not one of danger, for usually there is considerable alarm ex- 
pressed in regard to its occurrence. The first consideration 
should be an examination into the condition of the digestive 
apparatus, for it is in some fault of the gastro-intestinal tract 
that nine- tenths of all vertigos have their origin. 

Adenoid vegetations, by their interference with the general 
health of the child, and also acting as a local cause, are responsible 
for many of the cases of vertigo. At times there also occurs an 
accompanying deafness, which persists for some minutes after 
the occurrence of the vertigo, so that sudden and transient vertigo 
and deafness occurring in a child are at once suggestive of adenoids. 
The influence of eye-strain would indicate itself by brow head- 
ache, by a watery condition of the eyes when they were put to use, 
and by the evident straining which takes place to overcome the 
deficiency in sight while the child is at close work. 

Of course, vertigo occurs as part of other conditions, and most 
21 



322 VERTIGO 

notably in night terrors and in epilepsy. In the latter it may 
be a rather prominent symptom, so that the patient, when he 
feels the sensation coming on, actually turns about to maintain 
his balance, but quickly falls and becomes unconscious. In other 
instances the vertigo is described as accompanied by a noise, which 
is rushing in character. Auditory vertigo is a common accom- 
paniment of cerebral tumor and cerebral abscess. Attacks of 
vertigo are common in the so-called functional heart disorders 
of childhood. 



DISTURBANCES OF CONSCIOUSNESS 

Loss of consciousness may have a gradual or a sudden onset, 
and either type may exhibit varying degrees of completeness. 

The least marked of all forms is that which is known as somno- 
lence, and which is characterized by a persistent drowsiness from 
which the child is readily aroused. Stupor is more marked in 
degree, and is evidenced by a persistent sleepiness from which 
it is difficult to arouse the child, and when this is done, it is only 
for a very short time. 

Coma is still more profound, and it is impossible to arouse the 
little one, no matter how severe the measures used. Coma vigil 
is evidenced by the child lying with open eyes, but remaining 
absolutely unconscious. There may be an associated delirium, 
with active movements of the extremities. 

Diagnostic Significance. — Somnolence has no special sig- 
nificance, except as it is the first stage in a gradually developed 
coma and so indicates the occurrence or imminence of such. 
Stupor is observed also as the condition between coma and somno- 
lence, but irrespective of this connection it is observed most 
frequently in asphyxia from any cause. Coma may be suddenly 
developed, as is typically seen in insolation. Syncope is a sudden 
loss of consciousness which is due to brain anemia, and such 
may occur from violent muscular exertion, independent of inso- 
lation. 

When coma is gradually developed, it may depend upon one 
or more of several conditions. It is the usual accompaniment of 
narcotic poisoning and uremia. It may accompany any of the 
febrile diseases, and particularly the acute infectious ones, pyemia, 
septicemia, emboli and thrombosis of the brain, injuries to the 
head or brain, or to inflammatorv disease of the same. It is 
usual after attacks of eclampsia and occurs with epilepsy. 

Poisoning from opium is evidenced by very deep, slow, and 
shallow respirations and an infrequent but full pulse. There is 



324 DISTURBANCES OF CONSCIOUSNESS 

normal temperature and the pupils are markedly contracted, 
but equally so, which latter is very important to determine. 

In uremia it is rare that unconsciousness develops without 
convulsions. The pupils are either normal or equally dilated, and 
the pulse of a high tension and infrequent. No reliance can be 
placed upon the temperature. Edema is usually evident in some 
portion of the body. 

The coma occurring with epilepsy offers little difficulty in dis- 
tinction. There is the history of the fit, but, even regardless of 
this, there is usually the evidence of such in the bitten tongue 
and the bloody foam (clear when no injury occurs) about the 
lips. The face is greatly congested and the breathing stertorous. 
Coma is of short duration, showing progressive improvement 
until full consciousness is restored. Almost invariably the bowels 
and bladder have been evacuated during the seizure. 

Syncope is readily recognized by the pallor of the face, which 
is so marked, by the weak pulse, shallow and almost imperceptible 
respirations, and the widely dilated pupils as they are seen through 
the partly open eyes. The cause may be evident and is usually 
an emotional one. If there are added to the foregoing symptoms 
cyanosis and some stertor, the cause is probably a cardiac one. 

Insolation would be suspected from a history of exposure, in the 
heated term, and if the skin was unusually dry and hot. The 
conditions under which the child is found would help in deter- 
mining the occurrence of poisoning from illuminating gas and 
from alcohol. Hysteria is rarely the cause of coma, and the 
disease itself is rare before the seventh year. The coma is never 
deep, and the stigmata of the disease are usually well marked. 



DELIRIUM 

This state of mental agitation is evidenced by marked rest- 
lessness, incoherent mutterings, delusions, and sensory perver- 
sions. It may be active, in which state it is difficult to restrain 
the child, or may be muttering, in which the little one lies quietly 
enough but with very evident mental agitation. 

Delirium occurs with great frequency during the course of 
febrile diseases and quite regardless of the intensity of the pyrexia. 



DELIRIUM 325 

In some conditions it is more evident with low temperatures 
than in others, and this is particularly true of typhoid fever, 
in the course of which it commonly occurs. It is intimately 
associated with inflammatory cerebral disease, the septic infections, 
and uremia. In hysteria it may be marked, as it is in the insan- 
ities, both of which are not common to childhood. 



CONVULSIONS 

A convulsion is a series of muscular contractions which, while 
they are involuntary, affect the larger portion of the voluntary 
muscles of the body, causing thereby spasmodic movements. The 
most natural division is into those which are clonic, or epilepti- 
form, and those which are tonic, or tetanic. As a rule, tonic 
convulsions have their origin in the motor tracts of the spinal 
cord ; those of the clonic type, in the cerebral cortex. 

A spasm is a violent involuntary contraction of a muscle, pro- 
ducing rigidity of the same, which is either immediately followed 
by relaxation (clonic spasm), or which remains unchanged for a 
considerable length of time (tonic spasm), hence, generically, 
any involuntary and rigid contraction, especially the constriction 
of a canal, orifice, or hollow organ. 

The term "spasm" is applied to a contraction of either the 
voluntary or involuntary muscles, while "convulsion" denotes 
contraction of the voluntary muscles, producing visible move- 
ments, particularly one in which a number of the muscles are 
involved and the movements are more or less complicated. For 
exactness in diagnosis it may be well to bear the distinctions in 
mind. To the laity, however, there is absolutely no difference; 
convulsions are called spasms (and vice versa), fits, and spells. 

In taking a history care must be exercised to find out exactly 
what condition is being described, as the admixture of terms is so 
common. There are two quite natural divisions in which convul- 
sions or spasms may be placed — those accompanied with loss of 
consciousness, and those in which consciousness is retained. The 
first division may again be separated into — (a) those associated 
with a rise of temperature, and (b) those in which the temperature 
remains normal. For the sake of clearness such a division will 
be followed in this section. 

In many of the cases certain signs indicate that convulsions are 
threatened; these are irritability, restlessness, and sudden twitch- 
ings of the muscles of the face, arms, or legs. The last two are 

326 



GENERAL CONSIDERATIONS 327 

most noticeable during sleep, because at that time voluntary 
inhibition is not active. In the majority of instances, however, 
the onset is sudden and without warning. Sudden pallor of the 
face is immediately followed by rigidity of the muscles; the eyes 
are rolled upward and become fixed, and spasmodic contractions 
of the muscles occur rapidly, until the major part of the muscula- 
ture is involved. The contracture of the facial muscles causes 
peculiar grimaces, and the fingers are usually tightly clinched 
over the thumb, which is thus buried in the palm. 

The following symptoms, or some of them, may also be present, 
but are by no means constant : frothing at the mouth ; unnatural 
rattling or gurgling sounds, which are produced in the larynx; 
cold perspiration over the head ; and evacuations of the bowel or 
urine. 

The severe spasmodic movements usually persist for three or four 
minutes, leaving the child relaxed, exhausted, and in a condition 
of more or less profound sleep, from which there may be a bright 
and conscious awakening, or a semiconscious state persisting 
until the advent of a second convulsion. This sleep may at times 
resemble true coma. 

During the attack there may be spasm of the respiratory mus- 
cles, the breathing being shallow, irregular, and spasmodic, and 
accompanied with more or less cyanosis. It must be clearly 
understood, however, that the whole symptom group as described 
may not occur in every case, for there are all degrees of variety 
and severity, from slight twitchings to that type which may 
immediately destroy life. No matter how slight, the only neces- 
sary symptoms of eclampsia in the child are unconsciousness and 
clonic or tonic muscular contractions. 

It is hardly probable that an attack of convulsions would be 
unrecognized, even if not observed, for the parent's description of 
such an attack is usually vivid enough to preclude any error. The 
difficulty will come in diagnosing the cause of the convulsion, 
and this must be done as early as possible, for without such 
knowledge there can be no intelligent treatment. 

Before we take up the diagnosis in detail, I think that a lew- 
general statements will be helpful. 

The very young infant is comparatively free from convulsive 



328 CONVULSIONS 

seizures, because during the first three months of life acute sys- 
temic bacterial toxemias, which are so potent in the production 
of convulsions, are not frequent. Then, again, stimulation of 
cortical motor centers and of the convulsive centers at the base 
of the brain does not easily excite convulsive movement, because 
the nerve force discharged from these centers is hindered by the 
underdevelopment of the myelin sheaths of the fibers of the 
pyramidal tracts. These sheaths are developed gradually, so 
that at the third or fourth month the pyramidal tracts have their 
functions sufficiently developed to bring the spinal cells and the 
cerebral convulsive centers in close touch. 

From the third month until the end of the second year all of the 
nerve-centers of the infant are most irritable, so that convulsions 
are more common. Along with this irritability there is an enfee- 
bled inhibition, so that there is only a mild restraining influence 
exercised over spinal reflex movements. After the second year 
of life the nervous system is less irritable and inhibitory control 
is better, so that convulsions are less frequent. 



CONVULSIONS IN THE NEWLY BORN 
Convulsions are at times present in the newly born infant, 
occurring immediately after birth, or in some instances a few 
days later. Such convulsions are always of serious import. The 
cyanosis which is so commonly associated with these early convul- 
sions is the result of the abnormality which accompanied the 
birth, and as long, tedious labors are most apt to occur with the 
birth of first children, we see sufficient reason for the fact that the 
large majority of early convulsions occur in first children. On 
the other hand, rapid birth may result in injury to the child 
directly or indirectly by establishing an instability which makes 
it liable to convulsive seizure. 

These early convulsions are usually severe and persistent. 
They may be unilateral, but do not long remain so, as a rule 
rapidly becoming general; or if they remain unilateral, they are 
not confined always to the same side. A persistent one-sided 
convulsion is markedly indicative of local cortical injury, but to 
be attributed to this cause it must be persistent and all other 



CONVULSIONS WITH FEVER AND LOSS OF CONSCIOUSNESS 329- 

causes excluded. It is not uncommon to find that after the 
convulsions have ceased, even though they be of a moderate type, 
some weakness of the affected musculature is present. 

There are two conditions present which produce the irritability 
which gives rise to these convulsions — venosity and structural 
change inside the skull. 



CONVULSIONS WITH FEVER AND LOSS OF CONSCIOUSNESS 

Febrile Convulsions. — All conditions accompanied with a 
very rapid elevation of the body- temperature, which would 
ordinarily be associated with a chill in the adult, may be accom- 
panied by convulsions in the child. Usually the convulsive attack 
is the substitute for the chill which occurs in later life. If we 
except the first three months of life, then the younger the child, 
the more forcible this statement is. 

To be sufficiently assured that the convulsion is caused by the 
elevation of the temperature, one must take into consideration 
four factors : 

(a) The age of the child. It is very unusual that a child over 
the age of three years has an attack of convulsions as a substitute 
for a chill. Between the end of the third month and the end of 
the second year such convulsions are common, but during the 
third year and thereafter the assignment of fever as a causative 
factor should be more and more guarded. More often the cause 
of the convulsion is the toxemia which is itself the cause of the 
fever. 

(b) The temperature must be high and developed rapidly. 
Under 103 F. convulsions from fever are quite uncommon. 
Now, if the rise of a high temperature has been somewhat gradual, 
extending over a considerable period, one is not justified in 
attributing the convulsion to the temperature rise. Allowance 
must be made for the possibility, however, of a sudden elevation 
of temperature occurring during the course of a low or gradually 
developing fever. 

(c) The convulsions must occur early ; that is, within the first 
twelve hours of the febrile movement. If thev occur later than 
this, the cause should be looked for elsewhere. Usuallv the con- 



330 CONVULSIONS 

vulsion is such an early occurrence that it is the first thing to 
draw attention to the disease of the child. 

(d) There is practically no tendency to relapses ; the convulsion 
is not repeated, as a rule, is easily controlled, and the child quickly 
recovers its senses. One exception to this is that rare disease, 
the malignant type of intermittent fever, in which the sense 
recovery is rapid but the convulsion is repeated. 

Convulsions from Acute Bacterial Toxemia. — This is by 
far the most prolific cause of convulsions during infancy. Soluble 
products of bacteria capable of bringing on convulsions by their 
action upon the convulsive centers may be formed within the 
blood and tissues. This is encountered in the acute infectious 
diseases which are so prevalent during childhood. They may 
also be formed in the intestinal canal, as in the acute gastro- 
intestinal infections which are common to infancy. 

The intestinal form of bacterial toxemia being more common in 
early infancy (three months to one year), it follows that convulsions 
occurring during this period would suggest the probability of acute 
intestinal toxemia, and, on the other hand, the systemic infections 
being more common later, would indicate the onset of some one 
of the acute systemic bacterial infections. These are merely 
suggestive, however, never absolute. 

Convulsions of this type are very apt to be repeated, and 
whether they are or are not, the senses are liable to be left some- 
what dulled. Such convulsions are especially apt to accompany 
the onset of lobar pneumonia, scarlet fever, variola, and some 
cases of rubeola. When they occur at the onset of these, or any 
of the other infectious diseases, they indicate the severity of the 
infection. 

In determining the cause of the convulsion one must make a 
very comprehensive study of each individual case. This would 
include : 

Age, which has already been alluded to in detail. 

Hereditary influences: there is no doubt that the tendency to 
convulsions may be an inheritance, and this is indicated by the 
occurrence of convulsions from trivial causes in a whole family 
of children. Without a well-defined history of such, one must 
be loath to give this any prominence. 



CONVULSIONS WITH FEVER AND LOSS OF CONSCIOUSNESS 33 I 

Previous condition: If the convulsion was preceded by any of 
the usual prodromes of the infectious diseases, this would aid one 
in diagnosis. (See "Acute Infectious Diseases.") 

Surrounding and present general condition of the child, and 
especially all accessory symptoms which would in any way help 
to indicate the nature of the disease. 

An examination of the urine should be made under all circum- 
stances, for in this way alone can we feel satisfied in regard to 
uremia. 

Having eliminated as well as we can the probability of intestinal 
and also systemic toxemia, suspicion is directed to some organic 
disease of the nervous system, especially meningitis. Now, the 
types of acute meningitis which would be most reasonably mis- 
taken would be the acute purulent and the epidemic. In regard 
to the former, we know that it never occurs in a perfectly healthy 
child, but that there is some definite cause (as otitis or insolation), 
and without some such history one could readily exclude its 
existence. The epidemic form of meningitis is not so common, 
and rarely begins or runs its course with repeated convulsions 
early in the disease. 

It would be very easy to fall into error in diagnosis if one did 
not remember that not uncommonly lobar pneumonia occurs 
with repeated convulsions as a very prominent feature. So 
prominent are these, at times, that the convulsions and the 
subsequent somnolence almost completely hide the cough and the 
dyspnea. Such cases occur almost invariably during the first 
two years of life, and particularly during the first year. Under 
the influence of hyperemia, other symptoms may be added which 
would lead one to suspect a cerebral origin; these are, dilated 
pupils, irregular respiration, and stiffened neck muscles. 

This type of pneumonia is almost always confined to the apex 
of the lung. There are two things which we have to guide us in 
such cases: the temperature, which is low and more or less irregu- 
lar in meningitis, with cerebral symptoms of this kind, and the 
clearness of mind which occurs as soon as the convulsions are 
controlled when due to pneumonia. Within one or two hours 
after a convulsion, if it is due to pneumonia, the mind is perfectly 



332 CONVULSIONS 

clear, while in meningitis there is a marked dullness, which per- 
sists for a long time. 

Convulsions of Cerebral Origin. — These are very frequently 
the accompaniment of both acute and chronic diseases of the 
brain. Very many errors have been made in assigning a convul- 
sion to a cerebral origin simply because it happened to be uni- 
lateral. Such an assignment is not justified, unless the convul- 
sions continue to be unilateral over a protracted period. It 
cannot be too emphatically stated that unilateral convulsions 
commonly occur without the slightest indication of cerebral 
disease. 

It is necessary to remember, in the diagnosis of convulsions of a 
cerebral origin, that: 

(a) Brain disease does not usually begin with convulsions. 
An examination of the child, and especially a careful taking of 
the history, will almost invariably disclose the fact that for some 
time previous to the attack there have been some indications of 
brain disease. Frequently it takes just such an examination to 
bring out the fact of its existence. In the acute brain diseases 
these indicative symptoms will be headache, somnolence, retarded 
and irregular pulse, slight fever, mental dullness, etc., and in the 
more chronic cases there may have been more or less persistent 
and severe headache, indifference, change of disposition, etc. 

(b) Brain disease is not usually accompanied with very high 
rise of temperature (except acute meningitis) , and there is a marked 
tendency to recurrence of the convulsions. If the disease is of 
a chronic nature, the recurrences of the convulsions may extend 
over several days or even weeks, with more or less protracted 
intervals. A recurrence of this kind means one of two things 
in a child over two years of age — chronic brain disease or epilepsy. 
In infancy such a statement would not hold so true, for while 
it is not common, still occasionally there are cases of repeated 
convulsions, with somewhat lengthened intervals, which are 
entirely independent of brain disease. 

Chronic hydrocephalus is the only chronic brain disease of 
this period of life, and its recognition is usually easy, because of 
its characteristic symptoms. So, then, with this disease elimi- 



CONVULSIONS NOT ASSOCIATED WITH FEVER 333 

nated in infancy, we know that we are not dealing with brain 
disease. 

The condition of the fontanelle may be a guide in cases of doubt. 
It must not be forgotten that a protruding and pulsating fon- 
tanelle may be the accompaniment of any febrile state. How- 
ever, if this condition persists after the subsidence of the tempera- 
ture, or after it is considerably lowered, there must be some other 
cause for it besides the fever, and that cause is most probably 
cerebral. If the fontanelle is tense, it is strongly indicative of 
exudation within the skull, but the reverse is not true, for absence 
of a tense fontanelle does not in any way exclude the presence of 
an exudate. 



CONVULSIONS NOT ASSOCIATED WITH FEVER 

In children under the age of five years it is not infrequent to 
observe convulsions without any elevation of temperature. That 
the tendency to convulsions in such cases may be a direct inher- 
itance is indicated by the occurrence of convulsions from slightly 
active causes in whole families of children. Whether this is due 
to the direct inheritance of an abnormally feeble inhibitorv 
control or to a general neurotic inheritance of unstable and 
irritable nerve-centers is hard to determine. But, in any event, 
one should be guarded in giving heredity much prominence, until 
it is proved that several children in a given family were similarly 
affected. 

Rachitis is without doubt responsible for the conditions which 
act as predisposing causes in a large majority of the cases of 
convulsions in young children. 

Any general malnutrition, and especially rachitis, may bring 
about a peculiar susceptibility of the nervous system to convul- 
sive seizure, and in such a state it requires but a slight lv active 
cause to bring on an attack of convulsions. Usually, under 
these conditions, the first dentition shows the susceptibility. 
There is abundant reason why rachitis should induce convulsions ; 
it is a diseased condition, the result of perverted nutrition. Its 
most characteristic phenomenon is enlargement of that portion 
of the bones where growth is most active, and such enlargement 



334 CONVULSIONS 

is the result of excess of cartilaginous tissue and poor bone mod- 
ification of this tissue. 

A similar lack more than likely exists in the development of 
the nervous system, leading to an instability of the cells and a 
consequent tendency to nerve discharge. Undoubtedly inhibi- 
tion is also weakened. 

Convulsions in rachitic children may be unilateral, but they are 
not frequently of this type. General convulsions are much more 
common, and although they are not dangerous to the life of the 
child, there is but little doubt that they favor the development 
of epilepsy in later life. 

A fairly large proportion of the cases are associated with that 
condition known as laryngismus stridulus, although it may require 
some close questioning to bring out the history of the latter. 
Unless the attacks of laryngismus have been marked, they will 
go unnoticed or be attributed to something else. Generally, 
mild attacks are considered as an evidence of temper; under 
excitement of any kind the child will hold its breath for a consid- 
erable period, and this may be done repeatedly. It is in just 
such cases that a careful examination shows other evidences of 
rachitis. The statement cannot be too strongly made that a 
child may be rachitic and yet, as far as looks go, appear to be 
perfectly healthy except for a slight anemia. 

There are a large number of slight causes which may bring on 
an attack of convulsions in some infants and children which 
would have no influence upon the average child of corresponding 
age, and, underlying this, there is generally some condition of mal- 
nutrition. Every one of these causes must receive thorough 
investigation, for they are not sufficient in themselves to bring 
on a convulsion, but act as the active cause of an underlying 
condition (usually rachitis) . 

Just a few of the more common of these will be mentioned : 
passive hyperemia of the brain from pertussis, difficult urination 
from any cause, but more particularly from phimosis and calculi, 
constipation, partaking of unsuitable food, fright, and dentition. 
Causes acting from without are : suckling soon after an exhibition 
of one of the strong emotions (especially anger) in the nurse, 
suckling of an intoxicated nurse. 



CONVULSIONS NOT ASSOCIATED WITH FEVER 335 

Whenever the active or the remote cause is in doubt, a thorough 
examination of the urine should be made, irrespective of whether 
there is or has been any evidence of disease of the kidney or not. 
In every case of convulsions in childhood this procedure is a 
valuable one. 

Convulsions without any elevation of temperature, occurring 
in an infant, would have as their most improbable cause epilepsy ; 
while, on the other hand, if such convulsions occurred in a child 
over four years of age, epilepsy would be the most probable diag- 
nosis. 

Epilepsy. — Two very distinct types are recognized — grand 
mal and petit mal. 

Grand Mal. — One of the most important of the symptoms of 
this disease, as far as diagnosis is concerned, is the presence of 
an aura. This aura is rarely absent and may be motor or sensory. 
Motor aura is evidenced by local spasm, which may affect the 
head, face, hands, leg, or, in fact, any portion of the body. Sen- 
sory aura is almost endless in its variety of sensations; it may 
remain local or be general, being referred to any portion of the 
body or referred to any of the special senses. 

Whether the aura be motor or sensory, it has as its chief charac- 
teristic that in the same individual, over a protracted period, 
the same sensation or motor involvement persists. The aura 
itself lasts but a few seconds, but at times this period is long 
enough to warn the child of an impending convulsion. 

Immediately following the aura the convulsion comes on. The 
head and eyes are usually turned to one side and the face becomes 
very pale. The eyes are then turned upward and the pupils 
always become dilated; usually markedly so. Coincident with 
these symptoms, or immediately following them, there is a violent 
tonic muscular spasm, one manifestation of which is the throwing 
of the patient violently to the ground, and usually the fall is a for- 
ward one. The violence of the fall is one of the chief features. 
for there is never a sinking of the body, as occurs in a faint. The 
rotation of the head to the side is usually persistent, but is not 
necessarily constant. 

A cry which is inarticulate and hoarse, and never very loud, 
usually accompanies the first signs of spasm. From a sudden 



336 CONVULSIONS 

paleness, the face rapidly assumes a markedly cyanotic appearance, 
owing to the tonic spasm of the respiratory musculature. During 
this first tonic spasm the tongue may be badly lacerated by the 
teeth. 

All degrees of violence of the tonic spasm are encountered, 
but the foregoing description is of the average one, which lasts 
from three to thirty seconds. During this time the bowels and 
bladder are almost invariably evacuated, and this fact is of con- 
siderable diagnostic value. 

Clonic spasms immediately follow the tonic spasm, and the 
symptoms are those of general convulsive seizure (see first portion 
of this section). The duration of this stage is from one minute 
to one-half hour (usually about three minutes), after which there 
is a somewhat gradual subsidence. The respirations become 
normal again and the cyanosis perfectly clears up. Consciousness 
is rapidly gained, as a rule, but not completely for some time, 
the child remaining dazed and quite oblivious to its surroundings 
or to what has gone before. Generally there follows a period of 
deep sleep, lasting for one or two hours, and awaking from which 
complaint is made often of severe headache and general malaise, 
which may last for several hours. 

There is very little difficulty in diagnosing attacks of this kind — 
grand mal. The only probable confusion would seem to be that 
offered by hysteria, but in hysteria the warning cry is absent (or 
in the rare instances in which it is present, is very loud and more 
of a scream than a cry) and loss of consciousness is not absolute. 
The eyes stare, instead of being turned as in epilepsy, and there 
is no evacuation of the bowel. Evacuation of the bladder is also 
rare, but may occur as an incident in some seizures. The deep 
sleep following the attack is absent in hysteria. 

Petit Mal. — These minor attacks present great difficulty in 
recognition, because of the almost endless variety of symptoms. 
It is needless to go into detail in regard to these, for there is abso- 
lutely nothing about them which is of diagnostic value. Xo 
matter what the variety, their most characteristic features are 
brief loss of consciousness and slight local convulsive movement. 
The loss of consciousness may be only momentary, the child 
recovering almost immediately, with a consciousness that a 



CONVULSIONS NOT ASSOCIATED WITH FEVER 337 

period of unconsciousness has been present. Local convulsive 
movement may be so slight as to escape attention for a long time. 

Both the unconsciousness and the local convulsive movement, 
no matter how slight they be, are diagnostic of this type of epi- 
lepsy, if they recur habitually. The whole attack is so transient 
that there is no time for the cry or fall, as in grand mal. 

There is considerable difficulty encountered in the diagnosis of 
petit mal, because it is so extremely difficult to get a fair descrip- 
tion of such attacks from the mother. There is a marked tendency 
to deceive in this matter, and parents will show great ingenuity 
in explaining what they call "spells." This makes it important 
that we inquire into the disposition of the child, since the advent 
of these "spells," for their habitual occurrence, associated with 
a change in temperament or the evidence of increasing irritability, 
is quite a strong point in diagnosis. 

The organic type (Jacksonian epilepsy) is simply a peculiar 
type of epilepsy which has some distinctive manifestations which 
entitle it to separate consideration. It has as its essential path- 
ologic condition some organic disease of the nervous system, 
which may be due to injury or not. The influence of heredity 
is also strong. 

The onset is apt to be peculiar, in that after the aura (if there 
be one) some portion of the body is involved in an epileptic 
spasm. Usually the hand is the part affected, so that for a time 
the spasm is localized. It may then remain so, or immediately 
become diffuse, until almost all of the musculature is affected. 

Consciousness is affected by the severity of the attack and also 
by the situation of the lesion, which is causative. This tvpe 
usually begins before the tenth year of life. Even in the mildest 
of these cases well-marked mental impairment is the rule. Not 
uncommonly there is an associated speech disturbance and mild 
degrees of spastic palsy. 

Of great interest and of some diagnostic value are some general 
considerations of epilepsy, regardless of the type. In the great 
majority of instances the fits occur during the daytime; in a 
much smaller number, at night. A very peculiar fact in regard to 
nocturnal fits is that if the child sleeps during the daytime, the 



338 CONVULSIONS 

fit is apt to occur, so that there seems to be some condition induced 
by sleep which influences the occurrence of nocturnal fits. 

Then there are several conditions which apparently modify the 
occurrence of the convulsions. Acute illness is the most impor- 
tant of these, for it is very noticeable that while the temperature 
is elevated, there is at least a diminution in the number and also 
the severity of the attacks, which may amount to complete sub- 
sidence. However, there are exceptions to this, and this is 
during the acute infectious fevers, when, instead of a modification, 
we are more likely to notice an increase. 

Hysteria. — The hysterical convulsion is the most important 
of the motor manifestations of hysteria. It is not common in 
childhood, and the few instances in which it does occur are almost 
invariably limited to the period close to puberty. 

The onset is usually predicted by several days in which psychic 
symptoms are prominent, and immediately preceding the onset 
there occurs a symptom group which is always peculiar to the 
individual. This group may consist of a sensation of suffocation, 
headache, abdominal distress or sinking feeling, tinnitus aurium, 
or, in fact, any of a number of such sensations. It is possible 
that the attack may be ushered in by a cry, but this is very rarely 
the case, and in the few instances in which it does occur it is very 
loud and more of a scream than a cry. 

The convulsion is at first tonic and produces opisthotonos. 
This tonic spasm gives way to a clonic one, during which the body 
is tossed and jerked about somewhat violently by the muscular 
contractions. In from three to ten minutes relaxation follows, 
and may be ushered in by a light sleep which lasts but a few 
minutes. Awaking from this, the child is the subject of marked 
emotional excitement. 

During this stage there is the evidence of conscious deception, 
and following this there may be delirium or semiconsciousness. 
In other cases the convulsion is followed simply by profound 
sleep which may last for hours, the child awaking with paralysis, 
contractures, or anesthesia of part or of all of the body. Through- 
out the whole attack the emotional element is marked and loss 
of consciousness is never profound. Incontinence is not apt to 
occur, and the tongue is not bitten, as in epilepsy. 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 339 

The more common type of seizure is that in which there is a 
mild convulsive attack with partial loss of consciousness. The 
child may perform some special movement, or may imitate the 
actions of some animal, or may stand, lie, or sit in a fixed position, 
dazed and semiconscious. There may be localized spasm, and 
this may affect the diaphragm or the respiratory muscles or the 
esophagus. The emotional element is strong, however, even in 
these mild attacks. 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 

Tetany is characterized by tonic muscular contraction, which 
may be either continuous or intermittent. The musculature 
of the extremities is usually the most affected, both as to severity 
and frequency. The muscles of the neck, face, and trunk are not 
commonly involved in the spasm. Taken altogether, tetany 
is not a frequent occurrence during childhood, and when it does 
occur, it is often associated with laryngismus stridulus. 

The development of the spasm may be very sudden, or, in 
other cases, be preceded by sensory disturbances. The chief 
characteristic of the disease is the symmetrical contraction of the 
hands and the fingers; the hand is flexed at the wrist, the thumb 
being turned into the palm of the hand and the other fingers 
extended; in the interphalangeal joints are flexed the metacarpo- 
phalangeal ones, while the little and the index fingers approximate 
each other. When the feet are affected, they are strongly ex- 
tended, somewhat like a typical equino-varus ; the first phalanges 
of the toes are flexed and the second and third rows are extended. 
The plantar surface is quite arched, the dorsum being prominent. 

It is rare that the spasm of tetany affects more than the hands 
and the feet, but it may at times involve other parts. If forcible 
extension of the part involved in the spasm is attempted, con- 
siderable pain is caused. 

The duration of the spasmodic condition is from a few hours to 
several days, and without any subsidence during sleep. During 
any of this period the spasm may relax more or less completely, 
but only to recur again. The period of relaxation is for a shorter 
time than the subsequent period of strong contraction. 



34-0 CONVULSIONS 

There are three symptoms which are of considerable diagnostic 
import : 

(a) Trousseau's symptom: This observer noted that in tetany 
an exaggeration of the spasm would occur when pressure was 
made upon the large nerve-trunks or upon the arteries of the 
extremities. All that it is necessary to do to bring it about is to 
constrict the shoulder with a twisted handkerchief or towel. The 
compression is best made during one of the periods of partial or 
complete relaxation. 

(b) Chvostek's symptom: This is characterized by a spasm of 
the facial muscles when percussion is made over the facial nerve. 
Light percussion is all that is necessary. 

(c) Krb's symptom: This is that there is a markedly increased 
excitability of the muscles to the electric current. 

All these phenomena, due to the increased excitability of the 
peripheral nerves, may be observed not only during the period of 
marked spasm, but may persist for a long time after the contrac- 
tions have disappeared. So long as there is such a persistence, 
it is evident that the little one is not thoroughly convalescent 
from the attack. Even when the excitability is removed, the 
danger of other succeeding attacks is not over until the underlying 
conditions of disease or malnutrition are corrected. 

There are two etiologic factors which are prominent in tetany — 
age and rachitis. Tetany may occur at any age, but is most 
common in infancy, about 50 per cent, of the cases occurring during 
the first two years of life. Of the first two years, the first ten 
months show the largest number of cases, so that tetany is largely 
a disease of the first year of life. The reason for its common 
occurrence during this period is the prevalence of gastro-intestinal 
disorders, rachitis, and other forms of severe conditions of mal- 
nutrition. 

What changes take place in the nervous system to produce 
this syndrome we do not know, but whatever they are, they are 
temporary, for the disease tends toward complete recovery. The 
influence of rachitis as an etiologic factor is marked; that is, 
there are more or less marked symptoms of rachitis found in 
nearly all of the cases of tetany in infancy. The rachitis which 
is associated with tetany is usually of a mild type. 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 34 1 

The diagnosis does not present any difficulties, because of the 
typical symmetrical contractures and the periodic course of the 
disease. During the intervals of quiescence, use may be made 
of any or all of the three symptoms which have been already 
mentioned (Trousseau's, Chvostek's, and Erb's) to determine 
the existence of the disease. These same may also be of service 
in the detection of a latent tetany in an infant who is the subject 
of laryngismus stridulus. 

The only difficulty of recognition might come with those rare 
cases in which the spasm involves the trunk, and under these cir- 
cumstances tetanus might be suspected. In tetanus the muscula- 
ture of the jaw is most prominently affected and is also the earliest 
part affected ; then the neck muscles and those of the spine become 
subsequently involved, while the hands and feet are not affected 
with proportionate severity. In tetany the affection of the 
parts is quite opposite to that of tetanus, the contracture of the 
hands and feet predominating. Then, also, the contractions are 
not constant, but with periods of relaxation. 

Chorea. — This is a syndrome which is evidenced by involuntary, 
inconstant, and incoordinate muscular contractions, involving 
some part or all of the voluntary musculature and occurring 
during waking moments only. Various causes have been assigned, 
heredity, reflex irritation, anemia, physical and mental exhaus- 
tion, and toxins being a few of the many. It seems quite plausible 
that it may be produced by many organic lesions of the nervous 
system, by toxins, and by nutritional changes and derangements 
of function of the cerebral cortex. 

It is a well-established fact that at least one-fourth of all the 
cases of chorea are directly due to the poison of rheumatism. The 
percentage is much larger in many instances when we accept the 
observations of one man, but grouping the experience of a great 
many, there is no doubt whatsoever that at least 25 per cent, are 
due to rheumatism. 

Chorea begins, as a rule, between the ages of nine and thirteen, 
and it is rare before the fourth year of life. A neurotic family 
history is common and females are affected about three times as 
frequently as males. Of the exciting causes, fright is a very 
important one; then come gastro-intestinal disease, intestinal 



342 



CONVULSIONS 



parasites, imitation, etc. ; but whatever the exciting cause, there 
must of necessity be the predisposing conditions present of hered- 
ity, age, sex, etc., and the state of the blood. 

Preceding the symptoms which are characteristic of the affec- 
tion the child is anemic, nervous, and in a state of more or less 
malnutrition. The very first evidence of spasm may be in the 
clumsiness of the child in handling objects or in an inability to 
sit still. Such occurrences usually result in reproof, and the 
effort of the child to control the neurosis through the power of 
the will may result in a very transient period of repose, only to be 
followed by an exaggerated movement. Very soon muscular 




Fig. 97.— Testing for chorea reflex. When articulation is attempted, there is a distinct 

tremor in the hands. 



twitchings of the face, shoulder, or hand suggest that the child 
is not well. 

During all of this early period some children are able to control 
the movements to a considerable degree, but the presence of 
muscular spasm may be detected by directing the child to perform 
some delicate task of muscular coordination, and to do this 
slowly. Such an act (like the threading of a fine needle) will 
bring out the fact that choreic movements are present. After 
the early symptoms merge into the more pronounced ones, there 
is probably no more clearly defined symptom group than chorea. 

As a rule, the movements are mild at first, affecting but one 
member of the body or only a part of that member, then in a 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 343 

short time extending until nearly the whole body may become 
involved and the movements be severe. Usually by the end of 
the second week the maximum of severity has been reached. 
The severity may be such that movement is constant and the 
body is twisted and distorted so that the child is not able to main- 
tain an upright position. It is difficult to keep such children 
in bed, for the violent motion throws them about so that severe 
bruising may result. Between this severe type and the mildest 
cases there are all grades of severity. Usually the child is able 
to go about and has a limited control of the spasmodic movements, 
but all voluntary motion is accomplished by deliberate preparation 
and carried out with marked rapidity. Speech may be involved 
and the articulation is then jerky, or there may be a peculiar 
loss of control in the middle of a word. Choreic movements do 
not persist during sleep; that is, they may not cease absolutely, 
but they do subside markedly. Usually they cease entirely. 

Any portion of the body may be involved, but the most fre- 
quently affected portions are the face, hands, and arms. Then 
they tend to become general, and in rare instances may be lim- 
ited to one side of the body; but when they do, they do not differ 
in any particular from a general involvement. 

Choreic children, as a rule, are somewhat precocious, but with 
very poor mental control; they are irritable, capricious, and are 
easily excited. This mental condition is usually associated with 
a weakened physical condition, so that the body does not keep 
up with the activity of the mind. The mental condition results 
finally in loss of memory to some extent, and there is a change in 
the child's disposition. This change in the mental condition and 
in the disposition may be added to by a moral dullness, so that 
the child is not responsible entirely for its acts. 

In the severe types the musculature becomes exhausted by the 
constant movement and there is an apparent paralysis. But 
there is never a loss to electric reaction. Tendon reflexes are 
usually normal. 

Reference must be made briefly to the associated anemia, for 
it must be correctly interpreted, indicating the marked nutritional 
changes. In all cases the heart must be thoroughly examined 



344 CONVULSIONS 

and reexamined, as the close association of cardiac lesions and 
chorea is marked. 

The whole syndrome is so typical, when fairly well developed, 
that there is practically no chance for error in its recognition. 
Hysterical imitation might simulate it for a while, but in hysteria 
the movements are much slower and much more rhythmic in their 
character, and other stigmata of hysteria are present. 

During nervousness and convulsive tic the movement occurs 
most during periods of rest and quiet, and there is an absolute 
absence of clumsiness during voluntary motion. The choreic 
movements which sometimes follow hemiplegia are very slow 
and very irregular movements on voluntary motion, but are not 
spasmodic, like chorea. In addition, one discovers some organic 
lesion with its history and symptoms to guide in a correct diagnosis. 

The prognosis in chorea is good, mild cases recovering in three 
weeks, the average duration being ten weeks, and severe cases 
lasting for months. 

Habit Spasm. — This is a pure neurosis, and the name was 
first applied by Gowers in describing sudden and rapid contrac- 
tions of certain groups of muscles, which were but slightly notice- 
able at first, but which persisted until they became a habit. These 
movements are most common in the muscles of the face, neck, and 
shoulders. However, any part of the body may become affected. 

There may be only the winking of an eye, the shrugging of the 
shoulder, facial grimaces of various kinds, or any one or several 
of an unlimited variety of movements. At first such movements 
are only frequent, then finally they may become almost continuous. 
The affected child is generally an active, restless, and nervous 
one. The spasms are exaggerated by conscious observation, 
so that it is a point in diagnosis to make the child fully aware 
that he is being watched ; then, if the spasm is due to habit, it will 
increase in violence and frequency. 

The cases are more severe and the worst cases are always seen 
during the latter part of the child's school term, whenever that 
may be. It is not uncommon to find hyperesthesia of some 
part of the head or neck associated with habit spasm. There is 
very apt to be a change from time to time in the situation of 
the spasm, the same part not being always affected. 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 345 

The affection may continue for months or even for years. It is 
most common between the ages of seven and the period of puberty, 
and this is probably fully explained by one factor which is prom- 
inent at this period — school life. The general condition of the 
affected child is usually quite below normal, and there is generally 
a marked neurotic family history. 

The only possible difficulty in the diagnosis would be that 
offered by chorea (and, unfortunately, some writers refer to this 
affection as habit-chorea), but the fact that it is limited to one 
group of muscles is characteristic. 

Athetosis and Athetoid Movements. — These are a chronic 
form of spasm, in which the movements are slow, very irregular, 
and markedly incoordinate. As a general thing, the hand is the 
affected part, but there may be involvement of the face or the 
foot. They have been observed to occur in otherwise healthy 
children. Generally they are a sequel of the cerebral palsies. 
As there is no known treatment which is of the slightest avail, 
this may help to differentiate them. 

Head Nodding; Rotary Spasm. — These are considered to- 
gether, because in their etiology they are similar, and the only 
real difference is in the direction of the movements and the fre- 
quency. They are both rare forms of spasm and are observed 
almost exclusively during infancy. Of the two, head nodding 
is the rarer, and in this form of spasm the head moves with a 
vertical nodding motion. 

Rotary spasm, the more frequent of the two, consists of a side- 
to-side movement of the head, which may be very rapid and 
almost continuous, but which in most instances is slow. Xo 
matter what the direction of the movement, it is usually rhythmic, 
and vertical and rotary movements may alternate. It is not 
uncommon for the movements to cease for a time while the infant's 
attention is closely fixed upon some object of interest, but this 
is not always so. 

During sleep the movements cease entirely, and when the infant 
is free from excitement and in the prone position, all movement 
markedly subsides. It is common for nvstagmus to be associated. 
but the eye movements are much more rapid than those of the 
head. The movements of the head and the eye do not correspond . 



346 CONVULSIONS 

and any form of eye movement may be associated with any 
form of head movement. 

The duration of the affection may be several months, and 
there is usually a steady improvement, even without any treat- 
ment. It rarely occurs after the first year of life, and then, only 
as it may be associated with organic disease of the nervous sys- 
tem, is it at all common during the second year. 

Nystagmus. — This is a rhythmic, oscillatory, but entirely 
involuntary movement of one or both eyes, the movement being 
either from side to side or up and down. Nystagmus is always 
a sign of irritation, but this irritation may be general or local. 




Fig. 98.— Examination of the eye. If the patient be a rebellious infant, perfect control may 
be secured if he is held firmly upon the nurse's lap, the child's head being steadied between the 
knees of the examiner while the examination is made. 



Among the local causes may be mentioned : congenital cataract, 
corneal opacity, choroid or retinal disease, refractive errors of all 
degrees, and impairment of the normal vision from any cause. 

Of the general causes, it most often depends upon some organic 
disease of the nervous system. However, in concussion of the 
brain it may be an accompaniment or a sequel, but in either 
instance we are not sure of the reason for its occurrence. 

Hiccough. — This is a spasm of the diaphragm and is very 
frequently met with in all infants. Usually it is dependent 
upon some irritation of the digestive system, so that when it 
occurs with any regularity, the possibility of this as a cause should 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 347 

be investigated. Most often the fault will be found in the fre- 
quency or rapidity of feeding, not in the composition of the food. 
In other instances it is directly traceable to other irritation, as a 
cold bath, excitement, especially that causing laughter, etc., but 
this form follows the causative factor quickly and is not habitual. 

Occurring during the course of peritonitis or of intestinal 
obstruction, it is of very unfavorable import. Occurring in an 
older child and persisting, it is strongly indicative of hysteria 
or of a tendency to that condition. When it occurs during any 
prolonged or severe illness, it is indicative of a much lowered 
nerve tone, in which case it is of ill import, and of itself it is a 
very distressing symptom. 

Congenital Myotonia. — This is a rare condition and is usually 
hereditary. It is characterized by inertia of the muscles, being 
sometimes confined to one group, or involving in other instances 
all the extremities. Although present at birth, it is exaggerated 
later on in life, and especially at and after puberty. 

The characteristic feature of the disease is that after a period 
of repose, when an attempt is made to use the muscles affected, 
there is spasmodic rigidity which persists for a few minutes. 
The condition of the muscle is best described as inertia from 
slow initiative contractility and a delay in relaxation. There is 
tardiness in taking hold of anything and the same tardiness in 
letting go of the object. 

In the attempt to rise the same thing is noticed, and as the 
child tries to sit down, there is a similar hesitancy. ■ But all 
disability, no matter how marked at first, rapidly disappears 
under the influence of exercise. Mental excitation, on the other 
hand, tends to exaggerate the spasm. The affected muscles 
are larger than normal and are abnormally responsive to the 
electrical current. 

The diagnosis of congenital myotonia from all other conditions 
of a spastic type of contracture is made by its characteristic 
disappearance during exercise and its reappearance after a period 
of rest. From physiologic myotonia neonatorum it is differen- 
tiated by the disappearance of the latter with the normal develop- 
ment of the infant. The tonic spasms of the newly born which 
occur at times under the influence of sudden change of temperature. 



348 CONVULSIONS 

and which persist for only a few minutes, or at most a few hours, 
are all differentiated by their very transient course. 

When the disease affects the lower limbs, as is usually the 
case, it may not be noticed until the child makes the attempt to 
walk, then the trouble becomes quite prominent. With a careful 
review of the history, it will generally be noted that the infant 
never used the limbs very freely. 

Torticollis is considered in another section (see page 354). 

Laryngismus stridulus and spasm of the glottis are consid- 
ered in the section on "Laryngeal Stenosis" (see page 85). 

Tetanus. — In spite of the fact that the tetanus bacilli are so 
common and the opportunity offered by the body for their entrance 
is so large, yet the total number of cases of infection is very small, 
and the reason is found in the biologic o -chemical properties 
of the bacilli. Although there is but one recognized etiologic fac- 
tor for all forms of tetanus, yet it is advisable, for clinical purposes, 
to recognize the two forms occurring during childhood — tetanus 
neonatorum and tetanus traumatica. The symptom-complex 
is similar in both types, so that one description answers for both. 

The most prominent symptoms are those relating to the motor 
sphere; there is hardly a large muscle group in the body which 
escapes, although primarily and most severely the musculature 
of the head and neck is affected. 

Some days after an injury (which may not have been noticed 
at the time or thought of since its infliction) there occurs an indef- 
inite stiffness of the neck muscles and of those of the jaw. In the 
infant the result of the stiffness is an inability to nurse, with the 
consequent train of symptoms. The stiffness rapidly increases 
until the jaws are set and there is great difficulty in even partially 
opening them. The neck muscles are board-like in their tension, 
and the head is drawn backward. The face is set and the eyes 
are usually motionless, the alae nasi widely dilated, and the mouth 
increased in breadth and drawn downward. There may be added 
to this a peculiar facial grimace which is not unlike a painful at- 
tempt to smile. 

The muscles of the back and the abdomen are next involved, 
and when this occurs, the position of the whole body may be either 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 349 

one of three — opisthotonos, emprosthotonos, or pleurothotonos. 
As a rule, the upper extremity is not affected. 

When the disease continues, the legs, and especially at the knee- 
joint, become affected, but the feet and toes are generally spared. 
When the spasm becomes so general that it affects the muscles of 
the internal organs, the termination of the disease is usually and 
fortunately rapid. The diaphragm is generally markedly involved 
in the spasm. 

When well developed, the slightest movement will bring on an 
exaggeration of the spasm of the already tense and board-like 
muscles. Even the entrance of some person into the room may 
be sufficient to bring this about, and so make the suffering of the 
child more excruciating. Almost without variation the spasms 
are tonic, in rare instances being clonic. 

Cerebral symptoms are not apt to develop until near the time of 
death, when one may encounter delirium, but, unfortunately, in 
most of the cases the mind is clear. Perspiration is usually exces- 
sive and the tears flow freely and in great abundance. 

The temperature is usually very high during the attack, and 
just before death occurs it may rise still higher, in some instances 
reaching i io° to 1 14 F. For one or two hours after death occurs 
the temperature may still be high. 

With well- developed symptoms there could be but little chance 
for not clearly recognizing the disease. But not all of the cases 
are typical in their onset and development, and under these cir- 
cumstances an error in diagnosis is not unusual during the devel- 
opmental stage. 

A contracture of the muscles about the jaw may be present in a 
more or less marked degree in several conditions affecting the jaw 
and the oral cavity. Some of these conditions are an abscess near 
the masseter, dentition occasionally , facial neuralgias of severe type, 
hysteria, follicular tonsillitis rarely, and meningitis. 

It is not difficult to determine whether or not local conditions 
are responsible for a seeming trismus, and with such a determina- 
tion there is usually a clearing up of all doubt as to the occurrence 
of tetanus. An examination of the mouth under any of the above- 
mentioned conditions might meet with considerable resistance. 
but this would not be so marked that it could not finally be over- 
come. 



35o CONVULSIONS 

Of the general conditions which might lead to an error in the 
diagnosis, we have three — meningitis, hydrophobia, and strych- 
nin poisoning. 

In the first two of these, trismus is not a prominent feature and 
may be entirety absent. The cerebral symptoms of meningitis 
would serve to clearly distinguish it from tetanus, for in meningi- 
tis the mind is not clear, while in tetanus it is, until near the time 
of death. 

The history and the characteristic features of hydrophobia are 
always sufficiently marked, so that none but the most superficial 
examination would allow of error. 

In strychnin poisoning, there may or may not be a history of 
the ingestion of the drug, so that reliance must often be placed 
upon the other factors. It is especially true of strychnin poisoning 
that the spasms are most prominent in the extremities and this 
occurs very early. When trismus occurs at all, it occurs late. 

Tetanus neonatorum does not differ greatly from the traumatic 
form, but the mode of infection is through the umbilicus. Its first 
appreciable appearance is usually at the end of the first or the be- 
ginning of the second week of life. It is quite well proved that 
there is a racial predisposition, for in the island of Jamaica and in 
Guiana from 10 to 25 per cent, of all the negro children born die of 
the disease. Usually the first warning of the occurrence of the 
disease is the inability of the infant to nurse. When the attempt 
is made to grasp the nipple, it is suddenly released with a sharp 
cry, and this is the earliest evidence which we have of involve- 
ment of the masseter in spasm. Following this first indication 
there is apparently no difference in the development of the disease. 

Facial tetanus is a form of the disease which is so pronounced 
that it deserves some passing consideration. Its main character- 
istic is that one is not dealing with spasms of distinct groups of 
muscles only, but, along with them or preceding them, there is pa- 
ralysis of the facial nerve. It usually follows head injuries. 

Strychnin Poisoning. — Poisoning by strychnin is sometimes 
accompanied by spasms which are quite similar to those of teta- 
nus. It is not so much in the type of spasm as in the location of 
the same that there is a difference. The spasm of strychnin poi- 
soning seems to spend most of its force in the muscles of the ex- 



SPASMS WITHOUT THE LOSS OF CONSCIOUSNESS 35 1 

tremities. Trismus is never an early symptom, as it is in teta- 
nus, and it may not occur at all. The contracture of the muscle 
in tetanus never completely subsides ; it does have a period in which 
there is a partial relaxation, but this is never complete. In strych- 
nin poisoning there are definite periods during which there is a 
perfect relaxation. 

The history of the ingestion of the drug is valuable only if it is 
clearly obtained; the denial of such ingestion should have little 
weight if the other symptoms are suspicious. 



RIGIDITY OF THE NECK MUSCLES 

A contracture of the muscles of the neck which results in a stiff- 
ening of that part of the body, or which may be severe enough to 
result in complete immobility of the neck, is not infrequent during 
childhood. The degrees of the contracture vary within wide lim- 
its, the slightest degree being that in which the head is extended 
and passive motion is rebelled against, but at the same time the 
head is not thrown out of its natural position. In this form every 
attempt at enforced movement is accompanied by evident pain, 
at which the little one very naturally rebels. It is a simple matter 
to test the presence of the condition, for even with the mildest type 
of contracture, if the child is recumbent and an attempt is made to 
bring the head forward, there is pain, while in a normal condition 
there is no difficulty (and certainly no pain) in the procedure. 

If a contracture of this mild degree occurs in the course of men- 
ingitis and the child is somnolent, the effort to bring the head for- 
ward is difficult and the child gives evidence of pain. In the more 
severe degree the head is drawn and fixed to one side or may be 
forcibly drawn backward. 

When one considers the diagnostic value of this form of contrac- 
ture, it is advisable to distinguish between the acute form and the 
chronic. 

Acute Forms of Contracture. — The acute forms are most com- 
monly associated with the different forms of meningitis, and the 
origin of such contracture is undoubtedly due to a tonic spasm of 
the musculature of the nape of the neck, which, in turn, is caused 
by an irritation of the anterior cervical nerve-roots. 

The presence of backward contracture is usually first evidenced 
by the marked hollow which is present in the pillow upon which 
the child's head has rested. Children often assume apparently 
uncomfortable positions, and it is common to observe them with 
the head drawn back, but there is not the hollowing out of the pil- 
low unless the contracture is persistent. Of all forms of meningi- 
tis, contracture of the neck muscles is the earliest and most constant 

352 



RIGIDITY OF THE NECK MUSCLES 353 

in epidemic cerebrospinal meningitis. No matter how slight the 
effort to bring the head forward, the child rebels, and if the act is 
persisted in, there is unmistakable evidence of pain. At the same 
time if rotary or posterior movements are attempted, there is no 
evidence of pain being caused. As the musculature is palpated, 
it is observed to be hard and unyielding. 

The symptom is so early and so constant in the epidemic form 
of meningitis that if it is unmistakably present in a child who has 
been ill for thirty-six hours or less with symptoms of high fever 
and intense headache, and these have been present from the onset, 
the diagnosis of epidemic cerebrospinal meningitis is probable 
without further symptoms. If there is associated with these symp- 
toms a marked pain in the back, which is more marked when a 
change is made from the prone to the upright position, the diagno- 
sis is almost certain. One must be positive, however, that the 
child was well for some days previously, and that the onset was 
sudden with all symptoms severe from the very first. 

On the other hand, if the onset of the symptoms was apparently 
sudden, with an illness of a few days preceding, in which there 
was vomiting which was persistent and without apparent cause, 
and associated with slight fever and perhaps constipation, then 
the evidence would strongly favor a diagnosis of tuberculous 
meningitis. 

During the course of meningitis, if there has been a contracture 
of the musculature of the neck and coma supervenes with a con- 
siderable degree of relaxation of the muscles, it is a sign of grave 
import, indicating an early fatal result. 

When a contracture of the musculature of the neck occurs dur- 
ing the second week of an illness in which there has been a decided 
elevation of the temperature without persistent vomiting, then 
a diagnosis of some form of meningitis would be doubtful, even 
though the child was in a state of delirium or of somnolence. Such 
a condition would be much more suggestive of relapsing fever or 
of a serious typhoid. By the second week in either disease there 
would more than likely be present other corroborative signs. 

The retraction of the head which is associated with general mus- 
cular spasms, as is observed in cases of tetanus and in poisoning 



23 



354 ACUTE FORMS OF CONTRACTURE 

from strychnin, are both considered under another heading (see 
" Convulsions"). 

Torticollis. — This is generally produced by the contraction of 
one sternomastoid muscle, and associated with it there is usually 
some spasm of the posterior cervical muscles and the trapezius. 
There are various degrees of deformity, depending upon the num- 
ber of involved muscles and the extent of the involvement, so that 
in the mild cases there is an inclination of the head toward one 
side and a slight rotation toward the opposite side, while, when 
severe, the deformity is exaggerated and the head is held immobile. 
Modifications of these are observed as other muscles are affected, 
and if the trapezius is much affected, there is less rotation, but 
more inclination to the side and backward and the shoulder is 
raised. 

With an affection of both sides the head is drawn forcibly back- 
ward, and without rotation to the side, and it is held rigidly in that 
position. When the case is recent, there are usually localized pain 
and tenderness, and passive motion will overcome the contracture, 
in part at least. The condition may be congenital, and as such 
the cause is a subject of much dispute. It is not necessary to go 
into this discussion here, for until we have further definite knowl- 
edge, we must consider such cases as we do other malformations. 

Of the acute acquired forms, the most frequent cause is an irri- 
tation of the spinal accessory nerve from an enlarged cervical gland. 
During the acute infectious diseases these glands are commonly 
enlarged, and this is the explanation of the occurrence of torticol- 
lis during the course of these diseases. 

An exposure to direct draft may result in temporary stiffness. 
Sometimes torticollis is associated with acute or with phlegmonous 
tonsillitis and with retropharyngeal lymphadenitis, but it is far 
from being a common occurrence in the course of these affections. 
The pain is out of proportion to the amount of contracture when 
rheumatism is the cause, as it is very frequently in childhood. 
Torticollis of an acute form is sometimes observed as one of the 
many manifestations of hysteria, but it is not common, and the 
other evidences of hysteria are so pronounced as to allow of no 
error as to the cause. 

Chronic Forms of Contracture. — When one encounters a 



RIGIDITY OF THE NECK MUSCLES 355 

chronic and persistent contracture of the neck musculature in 
children, the cause is almost invariably found to be spondylitis. It 
is rare that the contracture is of the severe form, being in most 
instances that in which the head is simply extended, but with no 
retraction. In many instances the posterior muscles are the ones 
which are the first affected, but when the lateral muscles become 
involved, then the head is drawn to one side and we have a chronic 
torticollis. 

It is not unusual (in fact, when watched for, it is found to be 
common) for a chronic state of contracture of the neck muscles to 
exist for several weeks as the first and only prominent sign of cer- 
vical spondylitis. Sometimes the other symptoms are so indefinite 
that they are practically valueless in diagnosis, so that if one ob- 
serves a chronic contracture which has no discoverable cause, then 
one is justified in making the diagnosis of cervical spondylitis, even 
in the absence of other symptoms. 

One must always be guarded, however, against mistaking a form 
of contracture which is at first apparently chronic, but which upon 
investigation shows a distinctly periodic character, and which is 
due to malarial infection. The periodicity of such a condition 
and its disappearance under the appropriate treatment would clear 
up the diagnosis. 

The influence which severe burns have in simulating torticollis 
or rigidity of the neck musculature need only be mentioned, as the 
mistake of the true condition (of skin contracture) is only possible 
by the most superficial examination. 



PARALYSIS 

Paralysis is a partial or complete loss of voluntary motion. Pa- 
ralysis may exist if the loss of power is due to some disease of the 
muscle itself, or of the nerve influence which controls it. Inhibi- 
tion of the muscular function produced by disease which causes 
pain upon motion is sometimes called ' 'false paralysis," but it is by 
no means a paralysis, and care must be taken not to mistake it for 
such. 

According to the part which is affected, paralysis is classified 
as follows : 

Monoplegia : when one extremity is involved. 

Paraplegia: when two symmetrical extremities suffer loss of 
power. 

(a) Paraplegia cruralis: both legs involved. 

(b) Paraplegia brachialis: when both arms are affected. 
Diplegia : when two extremities are affected, but not symmetri- 
cal ones. 

Hemiplegia : one side of the body is affected. 

Crossed paralysis: when one side of the face and the opposite 
side of the body are involved. 

Local : when small groups of muscles evidence a loss of power. 

Multiple : when several parts are involved at one time. 

There is a still further division which depends upon the cause, 
as cerebral, spinal, neural, muscular, functional paralysis, and 
pseudoparalysis. 

According to the type of the paralysis, we have spastic paralysis 
(evidenced by an increase in the muscular tone, an exaggeration 
of the reflexes, and the subsequent liability to the occurrence of 
contractures) and flaccid paralysis (in which the muscular tone is 
diminished, reflexes decreased or abolished, and with no resist- 
ance to passive motion). 

In childhood it is usually possible to assign any paralysis to one 
of two types — either the cerebral or the spinal. 

Cerebral paralysis is chiefly characterized by a spastic condition 

356 



GENERAL CONSIDERATIONS 357 

of the musculature affected, by hemiplegia, exaggerated reflexes, 
and no change in electrical reaction. As a remote feature there is 
little or no atrophy of the muscles affected by the paralysis. 

Spinal paralysis is characterized by flaccidity of the muscles, 
paraplegia, diminished reflexes, and a decreased reaction to elec- 
trical stimulation. As a remote feature there is more or less wast- 
ing of the muscles affected. 

For the purposes of diagnosis in the paralysis of childhood these 
two latter divisions (cerebral, spinal) are most important. Before 
one can proceed to an intelligent understanding of the diseases 
which are responsible for the occurrence of paralysis, one must 



Fig- 99-— Testing the knee-jerk. Whenever possible, the stroke should be made with a per- 
cussion hammer. 



determine beyond any doubt the condition of the muscles, whether 
spastic or flaccid. If there is a flaccidity of the muscles involved, 
we think first, but not finally, of a spinal origin ; if there is spastic- 
ity, then the suspicion is of a cerebral cause. 

Spastic paralysis must not, however, be mistaken for the con- 
tractures which are observed after degeneration of the muscles, as 
is seen in infantile paralysis, neuritis, etc. In these instances there 
is a permanent flexion, and the resistance to passive motion is nor 
because of an increased muscular tone, but is due to actual change 
in the structure of the muscle. 

Monoplegia may be closely simulated by immobility of the limb, 



35 8 PARALYSIS 

which is entirely dependent upon the fear of pain which is caused 
by motion, or to an immobility from epiphyseal separation. In 
an older child pain would be complained of, but in a nursling it 
always seems easy for the parent to mislead by careless statement. 
Irrespective of the history, an examination including passive mo- 
tion would determine the difference. With epiphyseal separation 
there is more or less crepitation and an enlargement at the ends 
of the long bones. 

As the observance of the condition of the muscle is so impor- 
tant, it may be well to define briefly what is meant by muscular 
tone. Muscular tone means that condition of the voluntary mus- 
culature by which there is maintained a sufficient degree of tension 
to enable the muscles promptly to respond to nervous innerva- 
tion. Naturally, this tone varies under normal conditions, but 
only to a slight degree. Under the influence of fatigue, anemia, 
malnutrition, or any condition which tends to exhaust the system, 
there is a lessened tone. The best test to determine muscular tone 
is the amount of resistance offered to passive motion. The limb 
is grasped firmly and suddenly flexed, and if the normal tone is 
present, there is a very transient involuntary resistance, which 
rapidly disappears, so that the limb may be freely moved with but 
slight effort. Such a test requires the cooperation of the patient ; 
that is, there must not be resistance to the procedure, so that it is 
only adaptable for use in older children who are not fearful of the 
manipulator. Sometimes in younger children, by trying to make 
the desired motions as if in play, so as to gain the confidence of 
the child, and then suddenly diverting its attention, the test can 
be made satisfactorily. 



PARALYSIS IN WHICH THE MARKED FEATURE IS MUSCULAR 

FLACCIDITY 

When the flaccid condition of the musculature has been deter- 
mined beyond all doubt, the next consideration will be to bring 
out the fact as to whether the paralysis had an acute or a gradual 
onset. This is generally determined by the history of the case. 
The question to be decided is, "Did the paralysis follow a recent 
illness of a more or less severe type, or is the present condition one 



PARALYSIS WITH MUSCULAR FLACCIDITY 359 

which has occurred during or following an illness or an indisposi- 
tion of long standing?" 

Infantile Spinal Paralysis. — The diagnosis of this disease can- 
not be positively made until the time that the paralysis occurs. If 
prodromal symptoms are present, they are not distinctive or even 
suggestive, so that the occurrence of paralysis comes usually as a 
complete surprise. The paralysis is at first noticed in one or more 
of the extremities, and the instances in which one lower extremity 
is involved largely predominate. The cases in which one or both 
lower extremities are affected constitute about two-thirds cf all 
of the cases. The diaphragm, the muscles of respiration, and the 
sphincters almost invariably escape, no matter what the extent of 
the distribution of the paralysis. 

The most frequent period of development is during the second 
year of life, and four-fifths of all the cases are manifested before 
the third year is ended. After the sixth year it is of rare occur- 
rence. 

The cause of the disease is as yet unknown, and, like all diseases 
in which the etiology is obscure, many and widely varying causes 
are assigned by different authors. However, when one finds he 
is dealing with a disease which occurs in otherwise healthy chil- 
dren, almost invariably during the heated term, and generally 
with prodromal symptoms of fever, and sometimes of pain, the 
natural thing to think of as a cause is some toxic condition with 
a local lesion, or some infection which results in infectious embolism 
or thrombosis. 

The mode of onset varies. In a large majority of instances 
there are some malaise, high temperature, vomiting, and sometimes 
more or less pain in the limbs. There may also be a general hyper- 
esthesia, but, taken altogether, there is nothing definite about the 
onset. Such symptoms may persist for from one to four days be- 
fore the occurrence of paralysis. 

In a still smaller number of cases the child retires in apparent 
health, and upon awaking in the morning it is found that one 01 
more of the limbs are in a state of flaccid paralysis. In such cases 
there is no pain. The smallest number of cases are those which 
follow some injury or fall, and in these instances the paralysis may 
be almost immediate or may not appear for twenty-four hours or 
more. 



360 PARALYSIS 

A difficulty in diagnosis is encountered right at this stage, for 
there is nothing in the prodromal symptoms to arouse a suspicion 
of the disease, and so other diseases will be mistaken for it, either 
through haste in arriving at a conclusion or through too much re- 
gard for the prodromal symptoms. The onset of one of the acute 
infectious diseases, disease of the joint, rheumatism, and many 
other conditions will be diagnosed as a result of the early symptoms, 
and it is only with the occurrence of the paralysis that the diagno- 
sis is positively made. 

No matter what the type of the prodromal symptoms, the oc- 
currence of the paralysis is rapid. Within the first twenty-four 
hours the maximum has usually been reached, but this may at 
times be delayed until five or six days have passed, so that it is 
not well to prognosticate as to the extent of the paralysis until 
that time has elapsed. 

Then follows a period of from one to five weeks during which 
there is no apparent change in the condition of the paralyzed parts. 
The affected part is unusually flaccid, and this is usually not ac- 
companied by any pain or discomfort. The paralyzed limb is 
cold and cyanotic, but there is no persistent sensory impairment. 
If slight anesthesia be present at first, it quickly passes away. 
After this period of apparent unchangeableness, spontaneous im- 
provement occurs, and this may involve the whole of the limb or 
only a portion of it. 

It is generally recognized that the paralysis at first is always 
more severe and extensive than it is later on. The acute process 
seems temporarily to overwhelm certain structures, and as soon 
as there is a subsidence of the acute process, most of the impaired 
structures resume their function. The improvement almost always 
begins in the muscles which were last affected. The period of 
spontaneous improvement may last for three months. 

The next change is a very noticeable muscular atrophy. The 
affected limb is smaller than the corresponding one, and this change 
may be noted in a few cases as early as two weeks after the onset 
of the paralysis, but generally its occurrence is not until seven or 
eight weeks have elapsed. There is an arrested development of 
the whole of the affected limb, so that it remains smaller and 
shorter than its fellow. 



PARALYSIS WITH MUSCULAR FLACCIDITY 36 1 

The circulation in the limb is poor, so that it is cold, blue, and 
dead-looking. Under these conditions one would naturally expect 
the occurrence of bed-sores, and it may be helpful to remember 
that these never occur. 

As the paralysis is not permanently localized in all the muscles 
of the limb, but in some only, contractures are established because 
of the unantagonized contraction of the healthy muscles. This 
results in various forms of talipes. The extensors usually suffer 
more severely than the flexors, and in many instances the exten- 
sors are the only muscles affected. If the affected muscles are tested 
at this stage by the faradic current, there is found to be either 
complete absence or much diminished response. The galvanic 
reaction usually persists, and there maybe an altered polar reaction. 

During the acute stage bronchitis is a common complication and 
may be very serious. During the later stages there is one rare 
complication which ought to be kept in mind; that is, a chronic 
degeneration of anterior horn cells (with subsequent atrophy of the 
muscles) , which is superimposed upon a cord which has been injured 
earlier in life by infantile spinal paralysis. 

The diagnosis does not present very many difficulties in most 
of the cases. The difficulties of diagnosis at the onset, while only 
the prodromal symptoms are present, and the liability of mistak- 
ing other conditions, have already been referred to. When the par- 
alysis is limited to one limb, there is the possibility of mistaking 
some joint disease, and an early diagnosis may be very difficult. 
There is so much difficulty encountered during childhood in making 
tests by electricity that this means of differentiation is much less- 
ened in value. 

It is not always easy to make a clear distinction at first between 
infantile spinal paralysis and that analogous affection, infantile 
hemiplegia. There are many points of similarity between the two 
diseases : 

(a) Both affect children of the same ages (usually before the end 
of the third year and very rarely after the sixth year). 

(b) The cause of the paralysis is unrecognized. 

(c) The mode of onset is quite similar, in that paralysis quickly 
follows a few hours, or at most a few davs, after some indefinite 



362 PARALYSIS 

illness in which there may be high temperature, convulsions, vom- 
iting, etc. 

(d) The paralysis (the first positive symptom) in both diseases 
may become localized in an entire limb or be confined to some of 
the muscles of that member. 

(e) The sphincters are not involved, neither is sensation, unless 
transiently. 

The differences are as marked, however, as are the similarities. 
Cerebral paralysis is unilateral, and the usual form is hemiplegia. 
If but one extremity is affected, by a preponderating preference 
it is the arm; if two extremities, then it is the arm and the leg of 
the same side. In the spinal type the most frequent involvement 
is first one leg, and, if more extensive, then two legs. 

In cerebral paralysis there is an absence of any electrical change 
in the affected muscles, but, as has been stated before, this is diffi- 
cult usually to demonstrate. In the cerebral type the reflexes are 
exaggerated, wiiile in the spinal they are absent or much dimin- 
ished. 

After a case of infantile spinal paralysis has persisted for a long 
time, that is, until such time as the paralyzed musculature begins 
to show atrophic changes, it may readily be mistaken for one of 
the following conditions: muscular dystrophy, multiple neuritis, 
acute transverse myelitis, pseudoparalysis of scurvy or rachitis, 
and paralysis following acute meningitis. 

The distinction from muscular dystrophy is usually easy, for the 
history is so entirely different, but there are instances where it is 
impossible to obtain by any means a clear history of the sudden 
appearance of symptoms. Then the facts to be considered most 
carefully are that in muscular dystrophy all the limbs are usu- 
ally affected, and if it is of the pseudohypertrophic type, certain 
muscles are enlarged. 

There is not the coldness and the cyanotic appearance of the 
affected limbs which is so common in infantile spinal paralysis. 

Multiple neuritis is generally distinguished by its gradual onset 
and by the presence, more or less prominently, of sensory symp- 
toms, as pain (which is generally along the course of the affected 
nerve) and alterations in the sense of touch, temperature, and mus- 
cular sense (all of which are difficult to test in a young child) . Be- 



PARALYSIS WITH MUSCULAR FLACCIDITY 363 

sides this, there is often a history of antecedent diphtheria, and 
spontaneous recovery takes place in from two to three months. 

Sometimes the onset of multiple neuritis is sudden, with febrile 
symptoms and an early paralysis, and the sensory symptoms not 
at all marked; under these circumstances it is almost impossible 
to make a differential diagnosis. The course of the disease is the 
main point upon which one can depend. 

Acute transverse myelitis at the onset may simulate infantile 
spinal paralysis, but in the former there are decided anesthesia, 
exaggerated knee-jerk, ankle-clonus, and, what is quite distinct 
from infantile spinal paralysis, there is generally an involvement 
of the sphincters. 

In addition, there is a tendency to the development of bed-sores, 
slight wasting, and the reflexes at the level of the lesion are lost, 
but below it they are exaggerated. The main point, however, is 
that anesthesia develops simultaneously with paraplegia. Besides 
this the disease is very rare. 

Pseudoparalysis of scurvy or rachitis is a condition which must 
be considered, for several times the diagnosis has been made of 
paralysis when scurvy was present. The pain in the limbs, the 
extreme wasting of the muscles, and the general indefiniteness of 
many of the symptoms make the differentiation sometimes difficult. 

There should always be a search made for associated symptoms 
of scurvy, and the gums will give valuable evidence, especially if 
teeth are present. The spongy gums, the pain upon motion (es- 
pecially about the knees), and the general tenderness and hyperes- 
thesia all tend to exclude the spinal disease. 

The muscular weakness of rachitis is sometimes mistaken for 
flaccid paralysis, but the electric reactions are normal, the symp- 
toms are always bilateral, and other evidences of rachitis are 
present. 

Acute meningitis may be followed by paralysis with flaccidity 
and atrophy, and if seen at this stage, may simulate somewhat 
infantile spinal paralysis. The paralysis is, however, always pre- 
ceded by signs of irritation, and the sensory symptoms are usually 
marked. Pain is severe and increased by motion or pressure. 
The history would aid at once in excluding the possibility of any- 
thing but meningitis as the cause. 



364 PARALYSIS 

Multiple Neuritis. — The chief etiologic factor in children is 
diphtheria, although it is occasionally a sequel of other diseases of 
an infectious type, and particularly scarlet fever, malaria, ty- 
phoid, and rubeola. In all probability the inflammation depends 
upon direct action upon the structure of the nerves by the toxins. 
The etiologic factor determines to an extent the variety of the 
symptoms, for when following diphtheria, the soft palate is gen- 
erally involved. 

The onset of the disease is gradual, and it is usually from two to 
four weeks before the paralysis has reached its maximum of inten- 
sity. Even in those rare instances in which there is an abrupt 
onset, several days always elapse before the appearance of the par- 
alysis. One marked characteristic of the disease is that both 
motor and sensory symptoms are present and are the same in their 
distribution. The first symptom noted is generally a weakness 
of the muscles which later on will be the seat of the paralysis, and 
this weakness is gradual in its development until there is a com- 
plete paralysis. 

The paralysis may be confined to a few muscles in the extremi- 
ties, or may affect all four limbs. In rare instances there is an ex- 
tension to the muscles of the trunk and neck. The sphincters are 
free from any involvement. 

The weakness of the muscles which is an early symptom may be 
evidenced by the child being unable to use the muscles accurately. 
This may show itself most prominently in clumsiness in handling 
articles or in stumbling. In other cases there may be an inability 
to sit erect for any length of time, and in very young infants all 
that may be noticed may be irritability at being handled at any 
time. As the muscles of the hands and the feet are the most fre- 
quently affected, and the extensors particularly, there is often 
wrist-drop and ankle-drop. 

While the paralysis is increasing, the sensory symptoms begin 
to show themselves, and they are not prominent at any other time 
after this. The chief of these are pain and tenderness. This is 
usually most marked along the course of the affected nerve, and 
is followed by anesthesia of the affected areas. The pain is diffi- 
cult to demonstrate accurately in the young infant, but in older 
children it is observed to be clearly neuralgic in type and is in- 



PARALYSIS WITH MUSCULAR FLACCIDITY 365 

creased by pressure either over the nerve or the affected 
muscles. 

In from three to five weeks the anesthesia which has followed 
the early pain and hyperesthesia begins to show a slow but grad- 
ual improvement until there is complete recovery. If the child is 
old enough and of sufficient intelligence to aid in the tests, it will 
be found that the sense of touch, temperature, and the muscular 
sense are all about equally affected. Tests by the use of the elec- 
tric current are not of much diagnostic value, as they are not dis- 
tinctive, but they may be of prognostic import. 

Ataxia, tremor, edema, etc., may all be present, but they are 
far from being constant features and have no diagnostic import. 
Permanent flaccid paralysis sometimes persists in some member, 
associated with reaction of degeneration. 

The diagnostic features of multiple neuritis are the combination 
of motor and sensory symptoms with similar distribution, diminu- 
tion in electric response, atrophy, gradual onset, and wide-spread 
paralysis. When we find in a child that all four of the limbs are 
paralyzed, it is very suggestive of the disease, and if, in addition, 
the muscles of the spine and of the neck are involved, it is almost 
positive evidence. That the paralysis affects remote parts and 
is often incomplete is also suggestive. 

The diagnosis from infantile spinal paralysis may at times be 
difficult, because there is some apparent similarity in the etiology, 
and the paralysis in both instances has the properties of the periph- 
eral type ; that is, the response to the electric currents rapidly 
fails in the affected nerves and muscles, may be abolished, and the 
reaction of degeneration appear. The type of paralysis is also sim- 
ilar in that there is flaccidity followed by atrophy, with much 
diminished or lost reflexes, and the sphincters are not involved 
in either disease. 

However, there are marked differences also ; the mode of onset 
is almost always different, being very gradual in multiple neuritis 
and accompanied with pain and other sensory symptoms. The 
pain is usually a very early and usually severe symptom. There 
are occasional instances in which multiple neuritis has a sudden 
onset with fever, early paralysis, and few marked sensory symp- 



366 PARALYSIS 

toms, and in these cases the diagnosis from infantile spinal paral- 
ysis is only made by a study of the whole course of the disease. 

The spread of the paralysis is generally quite different in the 
two diseases; in infantile spinal paralysis a large muscle group is 
affected at the onset, with a gradual improvement later on, while 
in multiple neuritis the paralysis is apt to be slight at first with 
gradual extension until large groups of muscles are involved. 
Over the affected areas of neuritis, if there is any change, it is a vaso- 
motor one (there may be edema), but in the spinal disease there are 
coldness and cyanosis. 

Compression myelitis develops atypically at times, so that 
there may be a reasonable doubt for a while as to whether we are 
dealing with this disease or with multiple neuritis. The former 
may show other symptoms before the deformity or any other ob- 
jective symptoms of bone disease. The pain is radiating, there 
is stiffness of the spine in walking, and the loss of power is gradual. 
Increased reflexes and ankle-clonus are generally present and quite 
characteristic. Spinal caries should be suspected in every instance 
where the symptoms indicate transverse myelitis which has no 
apparently definite cause. 

Obstetric and all other forms of traumatic neuritis exhibit 
asymmetry, and it is not difficult to determine a sufficient cause for 
the condition. 

Transverse myelitis sometimes is manifested by a rapidly de- 
veloping flaccid paralysis. In the musculature so affected there 
may be a decided diminution in the response to the electric current. 
Not only this, but there may also be the presence of the reaction of 
degeneration and diminution or loss of the reflexes. If there is an 
overestimation of the importance of these symptoms and a disre- 
gard for the importance of a full clinical picture, a mistake might 
readily occur, and the disease would for a time be considered in- 
fantile spinal paralysis. With a detailed examination the dif- 
ferences would at once be evident, for in transverse myelitis anes- 
thesia is produced simultaneously with paraplegia, the two occur- 
ring at the same time whether they are complete or incomplete. 
Both the sensory symptoms and the motor ones are below the site 
of the lesion ; reflexes at the level of the lesion being lost, and be- 
low that exaggerated. The sphincters are involved. 



PARALYSIS WITH MUSCULAR FLACCIDITY 367 

Acute Meningitis. — This disease may occur and, following the 
attack, there may be at times a paralysis with flaccidity and sub- 
sequent atrophy. Coincident with the paralysis there is generally 
some anesthesia. The paralysis is always preceded by symptoms 
of irritation and the pain is usually very severe, being increased 
by the slightest motion or by pressure over the spine. Contrac- 
tures of the muscles of the occiput and spine usually follow the fore- 
going symptoms, and then finally the flaccid paralysis supervenes. 
Such a history would exclude the possibility of any other disease 
being the cause of the paralysis. 

Infantile Cerebral Paralysis (Antenatal Form), — In some 
of the cases of the antenatal form of infantile cerebral paralysis, 
instead of the rigidity which is so characteristic of the other forms 
of cerebral paralysis, there may be a flaccidity of the musculature. 
It is an unusual occurrence, and therefore must be remembered, 
otherwise it would lead to considerable difficulty in definite diag- 
nosis. 

In this class of cases the loss of power is usually not the most 
prominent symptom, so that the character of the paralysis need 
not be given so much thought as the other symptoms, and especi- 
ally those which refer to the mental condition of the infant. 

Acute Ascending Paralysis — Landry's Paralysis. — This is a 
very rare disease of early life with an obscure etiology. It is evi- 
denced by the occurrence of paralysis of a flaccid character, which 
may be preceded by mild and indefinite symptoms. The legs are 
first affected, then follows an extension upward, involving succes- 
sively every part of the body. The development is rapid (twenty- 
four to forty-eight hours), as a rule, but may take two weeks. 
Hyperesthesia is followed by anesthesia and loss of reflexes, but 
there is no change in electric reaction. No atrophy or involve- 
ment of the sphincters occurs. Death occurs in one week, as a 
rule; if recovery, it is after about three months' illness. 

Diphtheritic Paralysis. — This is not alone the most frequent 
form of multiple neuritis, but there are present peculiar features 
which entitle it to a special consideration. 

If lassitude and malaise occur in a patient who has been suffer- 
ing from diphtheria, it should at once excite suspicion, and this 
would be much strengthened if upon examination albuminuria 



368 PARALYSIS 

was discovered. The absence of knee-jerk would still add to the 
evidence, and if the symptoms of nasal voice and the regurgitation 
of liquids through the nose are present, they are almost path- 
ognomonic. 

The time at which the symptoms of paralysis make their appear- 
ance varies to a considerable extent. Symptoms may appear 
while the local lesion is still present, but this is unusual. On 
the other hand, they may be delayed until the tenth week after 
the lesion has disappeared; but this is also uncommon, and the 
average time is from three to four weeks. 

It is very common to observe a short period of three to seven 
days during which the child suffers from a more or less marked 
lassitude and malaise, and this precedes the occurrence of paralysis. 
It is frequently of service in giving warning of an impending 
paralysis. Closely following this there is a change in the voice, 
which becomes nasal, and is due to paralysis of the palate. At 
this time, if care is taken to observe it, there will in nearly every 
instance be found some weakness and tingling in the extremities, 
and especially in the legs. 

The knee-jerk is usually absent, and this is a most significant 
symptom, but the presence of knee-jerk, even with increased 
activity, does not exclude the diagnosis. Regurgitation of 
fluids through the nose is a very common occurrence, and in 
most instances this will be the first thing which will command 
the attention of the parents. The paralysis may involve the 
palate alone, or the musculature of the pharynx and larynx in 
addition. 

Besides the few cases in which the paralysis is actually limited 
to the throat, there are a larger number in which it is apparently 
so limited. I use the word "apparently" because a careful 
search will reveal evidences of paralysis elsewhere, although not 
marked enough to be determined without careful examination. 

After that of the throat, the next superadded paralysis is 
generally that of the legs, and the symptoms of paralysis in the 
extremities or in the trunk do not differ in any way from those 
which are due to multiple neuritis from other causes, except the 
absence of much pain. Associated with the involvement of the 



PARALYSIS WITH MUSCULAR FLACCIDITY 369 

legs there is generally an inability to use the eyes for any close 
work, owing to an involvement of the ciliary muscle. 

When the limbs are paralyzed, it is not complete, but is to such 
an extent that the symptoms to which it gives rise are those of 
muscular weakness with more or less flabbiness. There are no 
well-defined atrophies nor is there any pain (anesthesia is the 
rule) in the course of the affected nerve. 

At times there is a further involvement of the eye muscles, 
usually the external recti. If the third nerve muscles become 
involved, as is occasionally the case, then there may be a trouble- 
some diplopia. When the upper extremities are involved in the 
paralysis, it is of serious import, such cases usually dying from 
cardiac paralysis. When recovery takes place from the paralysis, 
it is complete. 

I have thought it well to leave the consideration of other 
features of the paralysis until this time, for they are of peculiar 
importance; these features are the involvement of the respiratory 
muscles and of the heart. 

Respiration paralysis may occur as a result of involvement of 
the phrenic or the intercostal nerves. The first warning is usually 
given by the occurrence of an attack of dyspnea which may be 
accompanied by a toneless cough. These attacks are generally 
repeated, and as time goes on they increase in severity and some- 
times in frequency. The breathing may be entirely thoracic on 
account of the involvement of the diaphragm, and the respirations 
are rapid, shallow, irregular, and evidently ineffectual. During 
these attacks, which are paroxysmal, the suffering of the child 
may be intense on account of the fear of immediate suffocation. 
If during these attacks there is the occurrence of vomiting, abdom- 
inal pain, and disturbance of the action of the heart, the case is 
practically hopeless. 

The symptoms which first lead to a suspicion of cardiac involve- 
ment are irregular and intermittent pulse. As the svmptoms 
increase in severity there are usually added pallor, restlessness. 
precordial distress, and coldness of the extremities. Within 
twenty-four hours after the first appearance of such symptoms 
death may take place. 

In other instances, which are in the minority, there is no appre- 
24 



370 PARALYSIS 

ciable warning of impending trouble, but after some unusual 
exertion a sudden paralysis of the heart occurs. The apparently 
well-marked crises which occur are nothing more or less than 
acute exacerbations of symptoms and conditions already present. 
Such exacerbations may last three minutes or be prolonged for 
several hours, and recurrences are the rule. Where death occurs 
from cardiac paralysis without warning and after a muscular 
effort, it is probably the heart muscle itself which is at fault, or 
there may be an associated toxic myocarditis. 

The diagnosis of this disease does not present any difficulties 
unless there is an absence of a history of a preceding diphtheria. 
In the presence of a paralysis of this type the history of even a 
mild attack of sore throat should arouse suspicion, for frequently 
such cases occur and the child has never been ill enough to take 
to its bed. While the faucial type of the disease (diphtheria) is 
the most common, it must not be forgotten that paralysis may 
just as readily follow diphtheria in other situations. 

The features which make the diagnosis most positive are the 
history of a preceding diphtheria, an involvement of the ciliary 
muscles, and an associated weakness of the limbs (especially the 
lower ones), and change in the voice, no matter how slight. 

Chorea. — This disease often has associated with it a paralysis 
which is partial and has flaccidity as a marked feature. Usually, 
when the paralysis is noticeable, it is evidenced by a decrease in 
the power upon both sides, and this is most noticeable in the 
limbs which are most affected by the choreic movements. More 
severe forms than this may occur and be localized; in the order 
of their frequency they are as follows: brachial, hemiparesis, 
and paraparesis. 

The paralysis is of early occurrence, following very shortly 
after the beginning of the choreic movements. Usually the first 
thing noticed is that the movements on one side of the body are 
very much lessened, and this is generally attributed to some 
general improvement of the child, but it should always arouse a 
suspicion of an impending paralysis. When a general improve- 
ment of the case is taking place, the lessened movement is general 
and not one-sided. 

Very soon after the event of lessened movement the arm 



PARALYSIS WITH MUSCULAR FLACCIDITY 37 1 

usually becomes almost if not completely helpless, and in walking 
the foot is dragged perceptibly. The paralysis of the arm may 
remain practically complete for a few hours, but after that the 
paralysis is never totally complete. The marked tendency is 
toward recurrences with successive attacks of chorea, but the 
type of paralysis is not the same in succeeding attacks. 

It is a very unusual happening for the paralysis to appear after 
the choreic movements have ceased, and yet in some instances 
this does occur. The usual course is for the two to disappear 
together, but in the few instances the paralysis may persist longer 
than the spasm. 

Chorea nollis is a much more severe type of paralysis than that 
just described; in this type the paralysis develops within twenty- 
four to forty-eight hours and involves the greater portion of the 
body. There is a complete flaccidity, but the choreic movement 
never entirely ceases ; it may be so slight as to need careful exami- 
nation to detect it, but it persists usually in the hand or the face. 

Now, in neither type of the paralysis is there any change in the 
cutaneous sensibility, and the electric reactions are unaltered. 
Even with a persistent paralysis there is never an atrophic change. 
The duration of choreic paralysis is from fourteen days to six 
months. A common chorea is rare under the age of five years; 
paretic chorea is most frequent at that age, so that this point 
may be helpful in the diagnosis. 

The paresis of chorea is in itself quite characteristic (excepting 
chorea nollis), having a somewhat gradual onset and an incom- 
plete paralysis of a flaccid type, in which the arm is much more 
affected than the leg, and the hand much more than the shoulder. 
In addition, there is no muscle-wasting or any pain. 

The diagnosis is somewhat simplified, for all cases of paralysis 
of sudden involvement (that is, less than twenty-four hours) can 
be excluded as being paretic chorea. Given a child between the 
ages of five and twelve with a gradually appearing paralysis of one 
arm or of one side, the probability of such a paralysis being 
choreic is almost a certainty. 

Hysterical chorea offers the greatest difficulty in the diagnosis 
when paralysis is developed. When hysteria causes paralysis, it is 
almost invariably complete, and especially so if it is flaccid. Asso 



372 PARALYSIS 

ciated with the condition there are other stigmata of hysteria, as 
hemianesthesia, "glove and stocking" anesthesia, amblyopia, etc. 

When a paralysis is of spinal origin with a slow development, 
there is associated pain and absence of the deep reflexes. Atrophy 
follows, the electric reactions are changed, and the distinction of 
this type of paralysis is so evident that a mistake is hardly possible, 
when any care is shown in the examination. 

If cerebral lesions exist, the resulting paralysis is of the spastic 
type, and there are associated with it the other symptoms of 
intracranial disease (cephalalgia, vomiting, convulsions, etc.). 



PARALYSIS IN WHICH THE MARKED FEATURE IS MUSCULAR 

SPASTICITY 

Infantile Cerebral Paralysis. — Under this term there are 
included several groups of cases which have certain common 
clinical features. A reasonable division of cerebral paralysis 
would be into three groups — prenatal, natal, and postnatal. 

The prenatal group of paralyses are due to defective develop- 
ment or possibly to intracranial hemorrhages, occurring late in 
gestation. At birth an infant so affected will show some loss of 
power, but this will usually not be the prominent feature. What 
is more noticeable is that there are spastic flexures or rigidity of 
one or more of the extremities. The type of the paralysis is 
generally diplegic or paraplegic. Later there are marked evidences 
of mental impairment, which may even amount to idiocy if 
the child lives. 

The natal group are probably nearly always due to meningeal 
hemorrhages or to asphyxia neonatorum. The instances in 
which prolonged or difficult labor and the use of forceps in delivery 
are blamed as a cause may exist, but such an origin is at least 
doubtful and always rare. The primary symptoms, as a rule, 
indicate clearly the extent of the lesion. If wide-spread, there 
are apt to be convulsions. 

Diplegia and paraplegia develop early, and are in themselves 
indicative of the extent of the lesion — a diffuse lesion resulting in 
diplegia, a less extensive one in paraplegia. Hemiplegia and 
monoplegia are rare. With the survival of the infant through 



PARALYSIS WITH MUSCULAR SPASTICITY 373 

the first stage, the secondary symptoms will depend upon the 
extent and distribution of the lesion. 

Usually there is more or less rigidity or spastic involvement of 
the extremities, but at times this is so slight that the child is 
brought for examination because of its general weakness and 
mental backwardness. In some of these cases the weakness of 
the limbs may be associated with a somewhat marked limberness 
of the neck, and this, with the general poor condition of the child, 
would suggest rachitis at first glance. 

The spastic condition of the extremities may be well marked 
and also may be constant or intermittent. Spasm of the muscles 
of the neck may result in head retraction, and spasm of those of 
the trunk and neck in opisthotonos. The general condition of the 
infant is always poor and it remains small and delicate. In rare 
instances the general nutrition remains good. There is always 
some degree of mental impairment, which it may be very difficult 
to demonstrate until the child is of a considerable age. Speech 
and hearing are both affected to some extent, but sight is rarely 
involved. Many of these children do not attempt to walk until 
they are three or four years old, and then it is not uncommon to 
observe that the gait is a crossed-leg one, so that they trip them- 
selves in the attempt; this is due to spasm of the adductors of 
the thigh. In severe cases the legs may be crossed while the 
sitting or prone position is maintained. There is an exaggeration 
of all of the reflexes. 

Muscular atrophy of the affected limbs is marked, and the limbs 
are both smaller and shorter than normal. It is not of unusual 
occurrence for the attendant to be deceived as to the true condi- 
tion, for often the history is such that one is led to believe that 
previous convulsions were responsible for the condition which 
exists ; then it is that athetoid movements in some of the members 
or a mild localized chorea lead to a suspicion of the real cause. 

Epilepsy develops in about one-half of all the cases, usuallv 
beginning as the Jacksonian type in the limb which was most 
affected, and then becoming general. 

The Postnatal Group — Acute Acquired Cerebral Paraly- 
sis. — The etiology is usually obscure, and in most of the cases it 
is impossible to determine whether the infant exhibited any appre- 



374 PARALYSIS 

ciable disability at birth or not. Heredity seems to play no part 
in its production. A history of parental syphilis without evidences 
of the disease in the child is common in these cases. As to the 
age of occurrence, the disease has its onset in two-thirds of all of 
the cases before the end of the third year of life. After the fifth 
year the disease is very rare. 

Diplegia and paraplegia are observed occasionally, but the 
characteristic form of paralysis is hemiplegia. The onset is 
sudden (the adjective acute implies that), and convulsions are 
present in over one-half of the cases. The convulsions are gener- 
ally repeated and may be followed by a state of unconsciousness. 
After the first thirty-six hours the convulsions are not apt to recur. 

There is an associated high temperature, and usually more or 
less vomiting, delirium, and other symptoms which are suggestive 
of some inflammatory condition in the brain, and these may 
persist for two or three days before the occurrence of paralysis. 
The temperature rise rarely precedes the convulsive seizure. In 
very rare instances coma takes the place of convulsions. 

If the lesion is extensive, all that may be noticed with the acute 
onset are diplegia, coma, and death, but this is the infrequent 
termination. The usual course is that there is observed a typical 
hemiplegia, with only a slight involvement of the face or with its 
entire exemption. 

The paralysis is at first complete, reaching its maximum of 
intensity between the end of the first and the first part of the 
second week, when there is usually a gradual improvement. The 
arm recovers more slowly than the leg. With left-sided lesions 
speech may be affected. 

During the height of the paralysis sensation may be abolished, 
while the deep reflexes are exaggerated on the paralyzed side. 
Spasticity gradually asserts itself and may always be detected 
when a careful examination is made. 

Laughing and crying bring out more clearly a stiffening of the 
features and a loss of expression which is present to some degree 
when half of the face is involved in the paralysis. There may be 
sluggish movement and overaction during volitional movement. 
Sometimes both sides of the face are involved in spastic paresis, 
but this is not indicative that the lesion involves more than the one 



PARALYSIS WITH MUSCULAR SPASTICITY 



375 



cerebral hemisphere; it is probably the result of muscle innerva- 
tion, so that the muscles subserving the bilaterally associated 
movements of the face are not as active as usual. 

The paralysis of the arm is most noticeable toward the periph- 
ery, and associated with it there is generally vasomotor paraly- 
sis, so that the limb may assume a dusky look. In the course 
of a few weeks the child may be able to walk by dragging the limb 
along. During the paralysis the leg has not suffered as severely 
as the arm, but the same feature is observed — that the paralysis 
is worse toward the periphery. While at perfect rest the position 
assumed by the lower limb is that of flexion with slight rotation 
at the hip. The foot drops somewhat, the toes in some instances 
being at right angles to the line of the metatarsus, or there may 
be equinovarus with flexed toes. 

When the limb is used in walking, the gait is peculiar, owing to 




Fig. ioo. — Measuring the lower limb. 



the limb being swung at the hip and brought across the body 
(generally too far), and also to the fact that, because of the short- 
ening of the limb, the walking is done almost entirely upon the 
toes. This results in compensatory tilting of the pelvis and 
perhaps some lateral spinal curvature. 

When the paralysis persists over a considerable period, there is a 
loss of proper development and consequent deformity. In the 
arm this is quite characteristic, as contracture develops there 
early. There usually is an adduction of the arm and the elbow- 
is turned slightly across the trunk and pressed into it. The 
forearm is flexed upon the arm (nearly at right angles) and semi- 



376 PARALYSIS 

pronated; the hand is flexed at the wrist and turned toward the 
ulnar side, the thumb being turned into the palm and the fingers 
tightly closed over it. 

The contractures which take place are usually so severe that 
even the use of considerable force while the child is completely 
anesthetized fails to overcome it. The distortions of joints and 
bone which take place under the influence of growth are varied 
and permanent. 

It is sometimes remarkable to observe the ability shown by a 
child in using such a limb. While the child is prone, the limb 
usually assumes the hemiplegic position, and to all appearances 
is a useless member, but with the child active, the difference is 
marked. With discontinuance of activity the position of hemi- 
plegia is resumed again. 

During the first days the reflexes may be diminished or lost, 
but after that they are constantly exaggerated. The plantar 
reflex is of the extensor type, unless the paralysis is very severe, 
when it is of the flexor type. The sphincters are not usually 
involved after the first acute onset symptoms have subsided. 

Hemianopia is common, but the great difficulty which is en- 
countered in determining it accounts for the fact that it is so 
often overlooked. To test for it it is well to use some object that 
the child really desires and move it across the field of vision, noting 
the expression when the object is passed over into the field in 
which vision is wanting. When hemianopia is of brief duration, 
it is simply indicative of an interference with the functions of the 
whole hemisphere, and this may accompany an acute lesion sit- 
uated at any portion of the hemisphere. When permanent, it indi- 
cates a permanent injury to the visual cortex. 

Hemianesthesia may or may not be present; it is difficult to 
demonstrate in a young child, and is of no diagnostic import. 

Aphasia is a very common occurrence and takes on different 
forms, but it is not permanent. The various forms are: 

(a) Aphasia may occur as a result of the same conditions as in 
adult hemiplegia, but it differs in that it is affecting parts which 
are not fully developed and the aphasia is therefore not permanent. 

(6) It may occur transiently when the speech centers are not at 
all affected. No matter what the situation of the lesion, there is 



PARALYSIS WITH MUSCULAR SPASTICITY 



377 



frequently an interference with the function of the hemisphere 
as a whole. 

(c) Aphasia occurs in this acute disease just the same as it 
may in the course of any other acute illness in which there is a 
marked lowering of the vitality in a child who has previously 
spoken some. 

(d) If the child has not already learned to speak, there is a 
delay in the use of speech, which may 
be so persistent as to alarm the parents. 

Disorders of movements are quite 
common as sequelae. They are chiefly 
of two classes : (a) defects accompany- 
ing voluntary motion, and (6) spon- 
taneous movements. Defects of the 
first class generally do not appear unless 
there is considerable voluntary motion 
possible. 

While voluntary movement is possi- 
ble, all the movements are executed 
with more or less evident effort, the 
action being both slow and stiff. This 
slow, stiff motion is most marked after 
the muscles have been at rest for a 
considerable time, and as the period of 
rest is prolonged, the stiffness is exag- 
gerated in proportion. Ataxia shows 
itself in the clumsy, uncertain move- 
ments. Choreic movements are very 
evident, especially when the attempt is 
made to perform some definite act requiring muscular precision. 

Spontaneous movements are usually of three forms : (a) Choreic 
movements appear when the spastic contracture is not marked. 
(6) Athetosis is a more common form than the preceding one, 
although both may appear in the same child. Unlike the choreic 
movements, athetosis is not marked, except in the parts which 
have suffered most — the periphery, (c) Tremor usually accom- 
panies motion, but may persist even during periods of rest. It is 
of all degrees. 




-Infantile cerebral paral- 
Child of seven years. 



378 



PARALYSIS 



As regards the deformities which occur, it is needless to enumer- 
ate them; all that is essential is to remember their mode of pro- 
duction, and then their nature is understood. There is an arrested 
development affecting the bones, the joints, and the soft tissues. 
The result is that the measurements of all the parts is below 
the normal, with two exceptions. The exceptions are when 
there is present a fat hypertrophy of the part and when athetosis 
and localized chorea are present in such a degree as to produce an 
actual hypertrophy. The atrophies are not from disuse of the 
members, but are due to cerebral innervation. They vary greatly 

in all cases, and this seems 
to be irrespective of the 
severity of the disease. 

The diagnosis between 
the congenital and the 
acquired forms may be 
impossible, for frequently 
the symptoms of the con- 
genital types are so mild 
that there is no attention 
drawn to them until the 
time arrives when the 
child ought to sit up or 
walk. The differential 
diagnosis of the forms is 
not so important, there- 
fore. 
There are instances where it is very difficult to distinguish this 
disease from infantile spinal paralysis. A history of an acute 
onset, absence of sensory symptoms, the atrophied limbs and 
deformities may be observed in both, but, on the other hand, the 
spasticity, the presence of perverse or spontaneous movements, 
preservation of electric excitability in the paralyzed muscles, and 
the retention of the deep reflexes are distinguishing signs of 
cerebral paralysis. 

The onset of the disease with its acute symptoms usually leads 
to a suspicion of the onset of one of the acute infectious diseases 
or of meningitis. The prolonged coma which is sometimes 




Fig. 102. — Infantile cerebral paralysis, showing 
contractures (Little). 



hand 



PARALYSIS WITH MUSCULAR SPASTICITY 379 

present helps to exclude the infectious diseases, and the absence 
of the usual symptoms which aid in differentiating the different 
infections and the occurrence of hemiplegia removes all doubt. 

From tuberculous meningitis the diagnosis at the onset is 
simple, for the prodromes of that disease are absent and the onset 
of cerebral paralysis is more acute. From acute meningitis or 
cerebral abscess - without apparent cause the diagnosis at the 
onset is difficult, if not impossible. The early loss of consciousness, 
the sudden paralysis, and the short duration of the acute symptoms 
help to distinguish the cases of infantile cerebral paralysis. 

Hereditary Spastic Paralysis. — This disease is evidenced by the 
occurrence of marked stiffness and rigidity of the legs, exaggerated 
reflexes, and contractures, but without atrophy or involvement 
of the sphincters. There is, as a rule, no sensory impairment. If 
the upper extremities are affected at all, which is very unusual, the 
involvement is very slight. Nystagmus is frequently present, also 
at times other ocular and cerebral symptoms, as amaurosis, 
mental impairment, idiocy, etc. There may be a difficulty in ar- 
ticulation. 

The disease arises from the fact that the nervous system of the 
affected child is not capable of maintaining its normal functions 
for more than a few years at most. Certain parts, although ap- 
parently normal, are not endowed with the capacity for prolonged 
service, so that their early decay is finally brought about. The 
decay is most noticeable in the pyramidal system of fibers and 
cells, although not limited to that section. Isolated cases occur, 
but usually there is a definite family history which is a great aid 
in the recognition of the disease. 

The diagnosis, of course, must be made from other conditions 
which exhibit a spastic paralysis resulting from lateral sclerosis. 
Slow-growing tumors may give rise to a similar condition, but there 
is an absence of any family history of like cases, and usually there 
is more or less pain present. 

Transverse Myelitis.— When this disease is situated in the cer- 
vical region, there is a general rigidity of all the paralyzed mus- 
cles. All the reflexes are exaggerated. Incontinence of feces 
is the rule, associated with retention of urine until the bladder fills, 
and then there is an incontinence of the overflow. 



3§o 



PARALYSIS 



The arms, the legs, and the trunk are involved in the paralysis, 
and associated with it there is anesthesia. The pupils may be con- 
tracted. When atrophy occurs, it generally affects the arms. The 
great danger to life is a paralysis of the muscles of respiration. If 
the site of the disease is the dorsal region, similar symptoms to the 
above are observed, with the exception that the arms are not in- 
volved and eye symptoms are absent. In the lumbar region there 
=™— j** is rectal and bladder in- 

i : *\ - volvement from the very 

^k l| first, in addition to the par- 

m alvsis of the lower extremi- 

ties. 

In the muscles affected 
there may be a decided 
diminution in response to 
the electric current, and not 
only this, but the presence 
of the reaction of degenera- 
tion. There is a diminution 
or a loss of the reflexes. In 
transverse myelitis, anes- 
thesia is produced simul- 
taneously with paraplegia, 
and this is important to 
remember in differential 
diagnosis. 

Paraplegia from Spinal 
Caries. — The clinical his- 
tory of a case of spinal caries is usually one of gradually increasing 
weakness (in the lower limbs only if the caries is in the dorsal or 
lumbar regions), frequently associated with a girdle sensation, 
occasionally by shooting pains and an interference with the func- 
tions of the bladder and the rectum. The disease is not uncom- 
mon among children. 

A typical case is not hard to distinguish. A child who is appar- 
ently healthy but perhaps not as strong as its fellows is found to 
tire more readily than before, and this tired condition is referred 
usually to the legs. If not complained of, it is noticed that the child 




Fig. 103.— An incorrect but common method of 
examining the back. The back, in this illustration, 
appears perfectly normal (see Fig. 104). 



PARALYSIS WITH MUSCULAR SPASTICITY 



38l 



sits a great deal, and is inclined perhaps for any sort of quiet play 
except that which involves the use of the legs. There may be 
no pain at this stage or there may be indefinite pain in the limbs 
which is apt to be complained of only at night. 

The disinclination for exercise and play becomes more and more 
marked, until the child is so weak that a stooping position is con- 
stant. With the stooping, however, there is an associated rigidity 
of the muscles of the back. 
If an examination is made of 
the legs at this stage, it is 
found that there is an exag- 
gerated knee-jerk and ankle- 
clonus, and commonly the 
plantar response is of the 
extensor type. 

Examination of the back 
may now show a slight an- 
gular curvature, and if so, 
the cause of the condition of 
the child is made plain at 
once. If the curvature is 
absent at this time, there 
may be a considerable de- 
gree of spinal rigidity, which 
would have the same signifi- 
cance as the angular curva- 
ture. 

It is not always, however, 
that one has the opportunity 
to see the child at this stage, 
and the condition continues 

on, until the little one is unable to walk. The condition then is 
one of marked spasticity ; the legs are closely drawn together and 
very rigid. The sphincters are involved, so that it is difficult for 
the child to control the action of the bladder, and impossible 
usually for it to control the action of the bowel. 

Girdle sensation is fairly constant, but among the earliest symp- 
toms is acute pain which radiates to the different points of nerve 




Fig. 104. — Illustrating a better and yet incom- 
plete method of examining the back. This is the 
same case as Fig. 103, and it is noted that when the 
clothing is removed sufficiently, a slight lumbar 
curve is discovered with slight tilting of the pelvis. 
For complete examination the child must be 
stripped. 



382 PARALYSIS 

distribution. No matter what the site of the caries, pain may be 
referred to the neck, the chest, or the epigastrium, or more rarely 
to the loins. When such pains occur and persist without definite 
and apparent cause, and associated with them there is more or less 
weakness of the lower limbs, it should always excite suspicion of 
caries. 

One must not expect always to find curvature; a considerable 
amount of inflammation of the membrane of the cord may take 
place without any appreciable bone deformity, and yet it may be 
sufficient to give rise to almost complete paraplegia. 

It is particularly true of caries in the lumbar region that there 
is but little deformity, but, on the other hand, rigidity is marked. 
It also occasionally happens that with caries in this situation the 
reflexes are not exaggerated, but diminished. 

In the cervical region angular curvature is also not marked, but 
instead there is usually a noticeable thickening about the spine 
and marked infiltration of the soft tissue of the neck. Then, again, 
the, arms are involved in cervical caries and local wasting of the 
small muscles of the hands is common. 

There should be a suspicion of this disease in every case where 
transverse myelitis comes on without definite cause. The great- 
est difficulty is encountered in the early stages, and especially where 
there is no appreciable deformity. This may make the diagnosis 
impossible for a time, and the only deduction that it may be pos- 
sible to make is that the child is suffering from a form of spastic 
paraplegia which is the result of pressure. 

The only safe method is to examine the back minutely in every 
case of spastic paraplegia. Not only should the examination be 
made of the spine externally, but where there is the slightest chance 
of the cervical region being involved, an examination should also 
be made by way of the pharynx. This latter procedure would nat- 
urally suggest itself when, in a child previously healthy, there was 
the gradual development of weakness in all four of the extremities 
and with a resulting spastic condition. When there is a defor- 
mity, the symptoms associated with it are such that a diagnosis is 
easy. It is the duty of the physician to make a diagnosis before 
deformity occurs, whenever such is possible. 



PARALYSIS WITHOUT FLACCIDITY SPASTICITY, OR ATROPHY 383 

PARALYSIS UNCLASSIFIED AS REGARDS FLACCIDITY, SPASTIC- 
ITY, OR ATROPHY 

Amaurotic Family Idiocy. — This is a rare disease. The usual 
history is that the child was perfectly healthy up to three or four 
months of age, when there occurred a weakness of the muscles of 
the neck which led to an inability to hold the head erect. From 
this on the weakness spreads until the trunk and limbs are affected 
and the child is the subject of a flaccid paralysis, which is later on 
changed to one of spasticity and atrophy. 

The knee reflexes are active in the flaccid stage ; then, as spas- 
ticity replaces flaccidity, the arms and legs are the subjects of jerky 
movements which are quite frequent. Wasting of the muscles is 
extreme, with unchanged electric reactions. With the occurrence 
of a sharp loud noise the extremities jerk quite vigorously. As- 
sociated with the muscular weakness, and coincidentally progres- 
sive with it, there is mental impairment. The child at first is 
simply dull and heavy, will not notice, and cares less and less 
for play. 

An early and constant association with the weakness of mind 
and body is weakness of. sight, and this may in part account for 
the child's early lack of interest. It is not long before blindness 
is complete. If the eyes are examined, the characteristic condition 
is noted; the macula looks like a dark- red spot, surrounded on 
all sides by a large area which is- very pale, the longest diameter 
being horizontal. The disc becomes paler and is eventually 
atrophic. 

The diagnosis is made by the physical and mental conditions 
(which are very similar to other diplegic conditions) being associ- 
ated with the visual defects and changes in the eye. 

Apparent Paralysis Associated with Joint Disease. — For 
the purpose of diagnosis I think that it is permissible to consider 
these conditions here, for while they are not strictly paralyses, but 
simply immobilities which are dependent upon bone disease, the 
clinical picture is usually so much like true paralysis that they must 
be thought of and recognized. 

With this apology for their insertion at this point we shall con- 
sider them. The paralysis which arises from spinal caries is not 



384 PARALYSIS 

included here, for it is a distinct and true paralysis, not simply an 
immobile condition due only to bone disease. 

Acute hip-joint disease sometimes induces a difficulty in motion, 
and particularly if the affection is bilateral. But most often the 
affection is of one leg, and that is held more or less stiffly. Usually 
when there is a bilateral affection, one joint is affected some time 
after the first one, but the disease runs a more rapid course in the 
last joint involved. The limping which is generally the first no- 
ticeable symptom is due to abduction of the thigh, external rota- 
tion, and to the flexion which is maintained by the tonic spasm of 
the muscles. Anesthesia will allow of free motion. 

It is not uncommon to see a child with considerable swelling of 
one hip or knee, or occasionally of the shoulder, and find that the 
child is in a state of apparent paralysis, but upon close examina- 
tion the cause of the disability is found to be rheumatism. 

Congenital hip dislocation results in a peculiar gait, and has more 
than once been diagnosed as a paralysis. As the child walks there 
is a lurch from one side to the other — generally more to one side, 
as the deformity is rarely equal. Examination shows unusual 
mobility of the hip, and the head of the femur is detected in an ab- 
normal position. 

The points of distinction from other conditions are : the normal 
bulk and conditions of the muscles, the normal reaction to the elec- 
tric currents, and the normal reflexes. 

Functional Paraplegia. — There is frequently encountered in 
the child a condition, following long or severe illness, in which the 
little one is unable to walk or to stand. This condition may be 
noted after a definite disease has persisted for some time, or it may 
follow an indefinite illness in which no diagnosis has been made. 

The loss of power is generally not complete. The child may be 
able to stand but not to walk, or may be able to do the latter un- 
steadily, or more often in a wavering way. The musculature is 
somewhat flabby. Instead of unsteadiness in the gait, one or both 
feet may be dragged along. The reflexes are overactive, as a rule. 
Hemianesthesia or stocking or glove anesthesia may be present. 

Its invariable occurrence is in children who are pampered, and 
this is the only feature which in any way gives us a clue as to its 
etiology. Yet when we consider the diagnosis, there is scarcely 



PARALYSIS WITHOUT FLACCIDITY, SPASTICITY, OR ATROPHY 385 

a condition which is so difficult of recognition when one does not 
expect its occurrence or is not well acquainted with its occasional 
appearance. 

If the associated symptoms have included sore throat, the dan- 
ger is of mistaking it for post-diphtheritic paralysis. Other cases 
will markedly simulate spinal caries with paraplegia. Cerebellar 
tumor may be suspected in some cases in which the gait is of a 
rolling character. 

The only possible way to diagnose it with certainty is by a rather 
tedious process of exclusion, for it may simulate so many condi- 
tions. Then, again, it occasionally precedes organic disease of 
the nervous system, and here lies another danger of overestima- 
tion or underestimation. One valuable aid in the diagnosis is 
separation of the little one from the mother, for in functional 
paraplegia this is followed by immediate improvement. 

Hysteric Paralysis. — This is not common among children, 
although in late childhood it is not so rare. Even when paralysis 
does occur, it is usually of a mild type. 

The condition of the. musculature may be that of flaccidity, with 
diminished reflexes and sometimes abolished knee-jerk, or it may 
be of a spastic type with exaggerated reflexes and contractures. 
The latter is the more common of the two. 

The degree of the paralysis also varies from a simple weakness 
to complete disability, the latter being the less common. Then, 
again, a few or many muscles may be involved. The type may be 
hemiplegic, paraplegic, monoplegic, or irregular. 

In the duration, in development, and in disappearance hysteric 
paralysis follows no rule: it may persist for a day or for years; 
it may come on suddenly or gradually ; it may disappear quickly 
or slowly. These very facts, added to the tendency to shift from 
one situation to another and to come and go, help to make the 
diagnosis clear. 

Such a paralysis is unique in that its occurrence cannot be ex- 
plained by any anatomic change in the nervous system. Aphonia 
is not uncommon and is usually quite characteristic; the voice 
may be completely lost very suddenly and as suddenly be regained. 
Or paralysis of the tongue may result in disturbances of speech. 

According to the degree and situation of the paralysis, there may 



386 PARALYSIS 

be manifold symptoms, as asymmetry of the face, club-foot, wrist- 
drop_, torticollis, spinal curvature, stenotic breathing, hiccough, 
squint, cough, dyspnea, dysphagia, and a host of others. Globus 
hystericus (sensation of a lump or ball rising in the throat) is one 
of the most constant occurrences in children. The dry, persistent, 
easily excited cough is another. Tremor is common, and when it 
occurs, usually persists for years and is annoying. Incontinence 
of either urine or feces is rare, and if these occur, they are not 
continued, but are intermittent or periodic. 

As to the diagnosis, paralysis is sometimes the only manifesta- 
tion of hysteria, so that absence of other symptoms does not of 
necessity exclude hysteria, so that one must in these instances be 
guarded in an opinion. Of course, if any of the stigmata of hyste- 
ria were associated with the paralysis, the diagnosis would be much 
simplified. 

In distinguishing hysterical paralysis from that of an organic 
origin, we have the absolute lack of conformity to the anatomic 
laws of distribution which is noted in most cases of the former. If 
the paralysis is hemiplegic, then the anatomic distribution more 
closely approximates the organic forms of disease, but it is not 
generally associated with paralysis of the tongue, with aphasia or 
an exaggeration of the deep reflexes, and, on the other hand, there 
is much more sensory change than is noted in organic paralysis. 
Another valuable point is that if anesthesia of the legs occurs in 
hysteria, the sacrum and the genital organs are not involved. 

A very common symptom-group is that of astasia-abasia, pro- 
duced by a settled idea in the mind of the child that it cannot walk 
or stand. Usually there is control of the limbs while the prone 
position is maintained, but none whatever when the standing or 
sitting position is assumed. When such a condition is noted, it 
makes the diagnosis certain. 



PARALYSIS IN WHICH THE HOST NOTABLE FEATURE IS 
MUSCULAR WASTING 

Muscular Dystrophy. — This is a term which may need some 
explanation, so that we may be perfectly clear as to its use. For- 
merly it was customary to describe several conditions under the 



PARALYSIS WITH MUSCULAR WASTING 387 

term "myopathy," but these are usually described now under 
the term "muscular dystrophy." This latter is the better term, 
for as far as our knowledge of the conditions goes, it more clearly 
indicates the nature of the disease. 

There are several types of the disease, and, while it is necessary 
to recognize these, it is an unsatisfactory division, for between all 
of them there are all degrees and grades which it is difficult to class. 
They all develop under the influence of heredity. The fact seems 
to be this: that there is inherited by the child some condition of 
the musculature which leads to its early destruction. Whether 
or not there is a relation with the nervous system is uncertain. 

The different types differ mainly in these particulars : 

(a) Pseudohypertrophic Paralysis. — This is the most common 
of the muscular dystrophies. The onset is in early life and almost 
invariably before the tenth year. The earliest symptoms are 
weakness of the lower limbs, and this is most noticeable when the 
attempt is made to rise from a sitting position (especially from the 
floor) and upon an attempt to go upstairs. 

Some of the muscles may be enlarged (usually the calves, but 
at times it may be muscular groups in the thighs or gluteal region) 
while they are the seat of paralysis, and others are atrophied. 
While the enlargement of the calves is sometimes very noticeable, 
the muscles are firm and very weak, owing to a displacement of 
the muscular fibers. 

Walking is late, and when accomplished, it is with an unsteadi- 
ness, so that the child trips and falls readily. Now, if an examina- 
tion is made during the early appearance of the muscular weakness, 
it is noticed that apparently the muscular development is much 
better than would be expected with such an amount of weakness 
as is evidenced. While the thigh may seem to be fairly well devel- 
oped, by a comparison with the musculature of the calves it will be 
observed that it is thinner than it ought to be. 

In regard to the trunk, the musculature of the pelvis and the 
back is usually weak, in consequence of which there may be a more 
or less marked lordosis. The shoulders are thrown far back. The 
alteration of the muscles about the shoulder is usually marked ; 
at first there may be slight enlargement, but wasting" is soon ob- 
served. The upper arm muscles are small and weak, while those 



388 PARALYSIS 

of the forearm may be firm and apparently unaltered as to strength. 
However, in an examination of the musculature in any situation 
great care must be exercised to distinguish normal firmness from 
that which is the forerunner of a state of pseudo-hypertrophy. 
Wasting of the small muscles of the hand is rare. 

(b) Juvenile Type. — This is much less frequent than the pre- 
ceding type, and so far as it follows a characteristic clinical course 
is evidenced by progressive wasting of muscular groups, especially 
about the muscles of the shoulder-girdle. Like the form previ- 
ously described, the disease begins in early life. 

Generally, by the time that the shoulder shows much wasting, 
there is a noticeable weakness and atrophy of the musculature of 
the lower limbs. In this type hypertrophy is not a marked fea- 
ture, although it may occur to some extent. 

The muscles of the foot and of the leg are usually not involved. 
There are no fibrillary twitchings, no sensory disturbances, and 
no reaction of degeneration, although the response to the electric 
current is diminished. The organic reflexes are never affected. 

(c) Infantile Facial Type. — This is characterized by the com- 
mencement of weakness in the muscles of the face, and it 
may occasionally be superadded to the preceding type (the juve- 
nile), in which the shoulder is most affected. The weakness affects 
principally the orbicularis palpebrarum and the orbicularis oris. 
This results in inability completely to close the eye or to pucker 
the mouth. The lips are usually thickened, but all the muscles 
of the face are atrophied, and this gives to the face a very peculiar 
expression. 

General Considerations of All Three Types. — The diagnosis 
should not be difficult when the characteristics of the different types 
of the disease are recalled. From progressive muscular atrophy 
due to degeneration of the spinal cord muscular dystrophy is dis- 
tinguished by the absense of fibrillary twitchings, the rarity with 
which the small muscles of the hand are involved, and the age at 
which the condition occurs. Then there is usually the history of 
similar cases in the family. 

In regard to the etiology, there is one point that seems clear, 
and that is that there is a very distinct hereditary influence. The 
condition is handed down from one generation to another, and sev- 



PARALYSIS WITH MUSCULAR WASTING 389 

eral children in one family may suffer. The male members suffer 
more frequently than the females, yet the females frequently trans- 
mit the disease. 

The course of the disease is progressively worse until complete 
disability ensues. The progress is in most instances very slow, 
lasting for years, so that the changes from month to month even 
are scarcely perceptible. 

Peroneal Form of Muscular Atrophy. — This disease is charac- 
terized by an early affection of the peroneal muscles, but from there 
it may be spread so as to involve the anterior tibial group or even 
the muscles of the calves. Generally the development of the dis- 
ease is symmetrical, but occasionally one leg is apparently affected 
more than its fellow. 

Wasting of the musculature is the marked feature, and natur- 
ally this is accompanied with more or less loss of power. Wast- 
ing takes place by a gradual disappearance of the muscular fibers ; 
there is never any hypertrophy of the muscles. Fibrillary twitch- 
ing is frequent, but not constant, and there occurs a gradual extinc- 
tion of faradic contractility. When the disease spreads from the 
peroneal group, it may involve the thighs, the upper arms, and 
rarely the pelvic and shoulder girdles. The face is not affected. 

Frequently the only symptom that a child will present at first is 
a decided wasting of the muscles below the knee, and when tested 
with the faradic current, there is no response. The ball of the 
thumb usually suffers next (some writers classing this as ' ' the hand 
type of muscular atrophy"), and the wasting is in no particular 
different from that which has affected the muscles of the leg. If it 
spreads from here, then the muscles of the forearms are involved. 
Now, the condition presented is this : the legs are wasted below the 
knees, the arms below the elbows. Deformities are the rule; that 
will be readily understood. 

The course which the disease takes is variable, for frequently 
there are observed periods during which there seems to be a per- 
fect standstill of all symptoms, and this may last for months. 
In other cases when one of these quiescent periods occurs, it seems 
to become permanent. The tendency, however, is to progressive 
change from worse to worse. This is without question a heredi- 



390 PARALYSIS 

tary disease, but what further etiologic factors exist we do not 
know. 

The diagnosis is made easy by the characteristic development 
of the paralysis and its distribution. There is practically no dan- 
ger of mistaking it for infantile spinal paralysis, as the onset is so 
very slow and the other features so entirely different. 

Muscular dystrophies exhibit features which are somewhat sim- 
ilar and may result in some difficulty in differential diagnosis, but 
the situation of the wasted parts, the frequent occurrence of 
fibrillary twitching, and the affection of the small muscles of the 
hand (when it occurs) offer points which should at once lead to an 
exclusion of dystrophies. 

Syringomyelia. — This is a very rare disease, and the name is 
applied to that condition in which cavities exist in the spinal cord, 
other than congenital malformations. As regards the symptoms, 
there are three distinct kinds: those which have to do with the 
muscular apparatus, sensory symptoms, and trophic disturbances. 

In regard to the first, there is progressive muscular atrophy, the 
atrophy in most instances affecting the small muscles of the hand. 
Associated with this there may be a wasting of the shoulder mus- 
culature and more or less marked lateral curvature of the spine. 
Unilateral paralysis of the face and wasting of the tongue may also 
occur, but this is certainly an unusual happening. Less fre- 
quently still, the muscles of the lower limbs are affected. 

The sensory symptoms show nothing which is constant. It is 
not infrequently the case that the limb which exhibits the most 
marked wasting suffers the least from sensory disturbances. The 
sensory symptoms which are characteristic when present are not 
so much of impairment as of dissociation of sensation. 

Heat and cold are not distinguished at all, yet the slightest touch 
is noticed. While the light touch will be detected, the child may 
often be jabbed with a needle and not complain, simply making 
the statement that some one touched him. This peculiar disturb- 
ance of sensation leads to injury, usually burns. This condition 
rarely affects the lower limbs, but may be observed in portions of 
the face, back, and chest. In a few instances there will be noticed 
no sensory disturbances at all. 

Trophic and vasomotor disturbances are usually very marked. 



PARALYSIS WITH MUSCULAR WASTING 



391 



Extreme redness of a limb is very common, and there is usually 
associated with this excessive perspiration of the limb. In other 
cases the excessive redness and sweating will become general. 
Sometimes the joints seem to be affected with a condition which 
disorganizes them. The bones are fragile . Other trophic and vaso- 
motor changes may be present, as ab- 
scesses, cyanosis, coldness, bullous erup- 
tions, etc. 

The diagnosis is made certain if there is 
that peculiar muscular atrophy associated 
with the characteristic sensory symptoms 
described and the vasomotor disturbances. 
But one or more of these may be absent; 
then a difficulty arises in distinguishing this 
disease from progressive muscular atrophy 
in which the small muscles of the hand are 
affected. To make the distinction clear, 
the history must be most carefully taken 
and the examination of the child must be 
most thorough ; otherwise errors are readily 
made. 

Cervical pachymeningitis may at times 
closely simulate this disease, and a child 
with wasting of both hands and upper 
limb with sensory symptoms might be the 
subject of either disease. But if the 
sensory symptoms were characteristically 

dissociated, then it would favor a diagnosis of syringomyelia. If 
this was absent, then one would consider the presence of lateral 
curvature, and in the absence of both the diagnosis would most 
probably be cervical pachymeningitis. The history is an aid, 
pachymeningitis having a more acute onset. 

Peripheral neuritis would hardly be mistaken, for the pain in the 
nerves, the diminution in the reflexes, and the history, especially 
of etiologic factors, would be of immense service. 




Fig. 105.— Scoliosis from 
syringomyelia. Female seven 
years old (Napier). 



ATAXIA 

Incoordination of movement, in which the act is imperfectly 
carried out, owing to the inability properly and accurately to ad- 
just the various muscular movements to each other, and which is 
known as ataxia, occurs in an acute and chronic form. Ataxia is 
especially liable to affect the lower limbs, and the result is a diffi- 
culty in either walking or standing, or there may exist an inability 
to do either. 

Under conditions which are perfectly normal there is a more or 
less pronounced swaying of the body when the child stands per- 
fectly erect with the feet close together. This swaying is forward 
and backward, as well as lateral, and if the eyes are tightly closed, 
the motion is increased at least 50 per cent. With even a slight 
impairment of the power of equilibrium the motion is increased 
in all directions. 

In a consideration of the ataxic gait a very clear distinction 
must be made between ataxic gait (in which there is imperfect 
coordination of movement) and spastic gait (in which there is rigid- 
ity of the limbs), as well as the gait which is due to weakness 
(in which one or both limbs behave as though they were partly par- 
alyzed) . 

In ataxia the lateral sway of the trunk which takes place in walk- 
ing is much increased (particularly when the eyes are closed) and 
it takes on an irregular character. As regards the foot, there is an 
increase in the outward sway and also in the height to which the 
foot is raised from the ground. The foot-fall is not regular. 

In the spastic gait the limbs are held rigidly and there is but lit- 
tle action at the knee. The foot is not well abducted, as is nor- 
mal, but instead may be slightly adducted, and it is scarcely raised 
from the surface. The result is that frequently the advancing 
foot interferes with the movements of the other by being carried 
in front of it. The sway of the body is much increased and is most 
noticeably toward the side which is opposite to the advancing foot. 
It is the sway that assists in the raising of the foot from the ground. 

392 



HEREDITARY ATAXIA 393 

This sway is associated with attempts at motion, and is not irreg- 
ular, like the ataxic gait. One of the chief characteristics of this 
gait is that it is much slower than the normal. 

In weakness the limbs act somewhat like pendulums, being 
swung into position instead of deliberately carried there. The 
weight of the body is not thrown upon the leg, which rests upon 
the ground until the knee has been slightly retroflexed. 

When we consider the etiology, we are able to place all acute 
ataxias in one of four groups : 

(a) The cerebral or spinal type : This is dependent upon some 
involvement of the central nervous system. 

(6) The neurotic: In this group there seems to be a distinct 
neurosis, and the child does not exhibit any organic changes in the 
nervous system. In this group are included hysterical ataxia (in 
the form of astasia and abasia) and the reflex ataxias (especially 
those dependent upon some sexual condition). 

(c) The infectious : Diphtheria leads in this group, but variola, 
scarlet fever, syphilis (in the second stage), and occasionally ty- 
phoid are all at times causative factors. 

(d) The toxic: This is the rarest group in childhood, because 
the little one is too young to be exposed to the influence of the sub- 
stances which are usually causative of this group (alcohol, arsenic, 
mercury, and lead). 

Hereditary Ataxia. — This disease almost invariably attacks 
the child between the ages of six and ten, and after the disease has 
once started, the course is usually progressive. It is not unusual, 
however, to observe periods of apparent quiescence which may 
persist for several months or a few years. 

The first symptom which is noted is difficulty in locomotion ; the 
gait of the child, instead of being steady and uniform, is charac- 
terized by an occasional lurching, the feet being brought down with 
increased force and not being placed in a proper position to main- 
tain a perfect balance. Even while the child is standing the feet 
are not well placed, but are widely spread apart in the effort to 
maintain a more stable equilibrium. Almost invariably the eyes 
are fixed upon the ground while the standing position is as- 
sumed. 

The difficulty in standing and in walking becomes progressively 



394 ATAXIA 

worse, until there may be an inability to do either. As the dis- 
ease advances other phenomena are added. The speech becomes 
affected ; the words are cut short, and this gives a peculiar explo- 
sive nature to their utterance. 

Movements of the hands and arms become involved (usually 
four or five years after the onset of the disease) late in the disease, 
and of still later occurrence is the affection of the head and trunk. 
Even in the presence of a very wide-spread involvement the sphinc- 
ters are but little affected, if at all. 

Muscular contractures finally take place, and these add defor- 
mities to the other symptoms. Humped foot is a common occur- 
rence (an excessive arching of the dorsum, hollowing of the inner 
and inferior aspect, and inversion), and a lateral curvature of the 
back may become at times extreme. Pupillary reaction remains 
normal, but nystagmus is a very common occurrence. The deep 
reflexes are almost invariably lost, but in some instances instead 
of this there is a marked diminution. General weakness is more 
or less evident, and anemia is usually marked. 

With the exception of some emotional disturbances or moderate 
instability, the mental condition of the child does not suffer. I 
know that this is not in accord with the popular view, but the er- 
rors of diagnosis have been so many in the past before the condi- 
tion was well understood that the view has gained credence that 
the mental condition suffers severely. 

The one prominent feature of the disease is its affection of more 
than one member of the family. It is usually this history which 
first leads to a correct diagnosis of the disease. It might be con- 
fused with hereditary cerebellar ataxia, but that is a disease of 
later life, being exceedingly rare before the twentieth year, so that 
we need not consider it at this time. Hereditary tabes dorsalis 
(juvenile) sometimes closely resembles in its symptoms hereditary 
ataxia. It is characteristic of the disease that it begins in early 
life (about the seventh year). 

Sometimes the very first symptom is that of lightning pains 
which are referred to the legs. This is almost always associated 
with weakness of the limbs, ataxia, and abolished knee-jerk. 
In other instances the first symptoms are those which affect 
the vision, and are the result of optic atrophy. These eye symp- 



HEREDITARY ATAXIA 395 

toms may increase to such an extent that blindness may super- 
vene, while the ataxia remains as a minor condition as regards its 
severity. The pupils remain inactive to light. 

One feature of the disease is the lost knee-jerk; this may be very 
noticeable (entirely lost or markedly diminished) even when the 
ataxia is so slight as to be scarcely observed. There are two 
features which are very pronounced in the etiology of the disease 
— heredity and the influence of syphilis. The lightning pains and 
the eye symptoms of this disease are absent in hereditary ataxia. 



PAIN 

It is almost impossible to formulate a perfect definition of pain, 
and I do not know that it is necessary to spend much time trying 
to, for we have all experienced it, although not always able to de- 
fine it. 

In infancy pain is very difficult of recognition, for many of the 
features which usually accompany it are present in conditions in 
which there is no pain appreciable. Some of these features are a 
tense pulse, hurried respirations, drawn features, restlessness, etc. 

Being a purely subjective symptom, its intensity and even its 
presence must be estimated by the manifestations of its presence, 
as one is able to observe them, by the nature and extent of the con- 
dition which is the probable cause, and, lastly and least important, 
by the statements of the child or its parent. 

Even in children of considerable age and intelligence there is en- 
countered much difficulty in determining both the existence and 
the intensity of pain. Recognition of the existence of pain is usu- 
ally left to the statements of older children, but this should always 
be substantiated by other evidences, and most of these evidences 
are used in the detection of pain in infancy. 

In childhood, when the child is too taciturn, when the child ex- 
aggerates or is incapable, for any reason, of accurately describing 
the sensation of pain, we rely more upon the evidences of it as seen 
in the drawn features, livid countenance, dilated pupils, shrieking 
or crying, the various assumed postures, the indisposition to move 
certain members, and so forth. 

By far the largest factor in the proper estimation of the existence 
of pain, and its character and intensity, is the ability of the observer 
to properly gage individual susceptibility, and this can never be 
learned from books. There can be no question as to the existence 
of very marked differences in pain perception in different children ; 
and, further than this, so many things, especially nutritional con- 
ditions, influence or modify pain susceptibility in the same indi- 
vidual at various times. Another element is whether the pain is 

39 6 



GENERAL CONSIDERATIONS 397 

acute or chronic, for children do not bear pain well at any -time, 
and if long continued, it finds the little one less resistant. 

Tenderness must not be confounded with pain, although the 
relationship is very close. It is the production of painful sensa- 
tions by pressure, and pain is usually associated with tenderness. 
This is not invariably the case, so that it has some value in diag- 
nosis, particularly in the recognition of transferred pains. Pres- 
sure over the part complained of by the child may elicit no pain, 
but when we are able to locate the cause of such complaint, then 
pressure over the point of real trouble shows tenderness. 

Mode of Onset. — If the onset of the pain is sudden, it is indica- 
tive of the acuteness of the causative factor ; if of gradual develop- 
ment, it proves to us that there is no solution of continuity, and 
that the causative factor is of slow development. Short duration 
of the pain indicates the same as acute onset; long continuance 
meaning the same as gradual onset. 

The time of occurrence is of some value. Headaches recur- 
ring in the late afternoon are almost always due to anemia or weak- 
ened heart. Pain at night is very suggestive of periosteal inflam- 
mation. Pain immediately following a meal is suggestive of some 
digestive fault, and if delayed for a considerable time and referred 
to the abdomen, then of some intestinal one. Then, again, we 
may have pain referred to some other functional act, as its increase 
or occurrence with respiratory acts, urination, defecation, etc. 

Character of the Pain. — This may be an indication of the na- 
ture of the cause : 

(a) Acute, stabbing pain is usually observed in the acute 
inflammations, and if radiating, it is suggestive of neuralgia or 
neuritis. 

(b) Dull pain occurs mostly as the result of inflammations of the 
mucous membranes, the parenchymatous viscera, or when inflam- 
mation has been of long standing. It is also seen in visceral affec- 
tions. 

(c) Constant and boring pain is encountered in affections of the 
bones and in periosteal diseases. 

(d) Aching pain or soreness indicates that the affection is of the 
musculature. 



398 



PAIN 



(e) Burning or itching pain is most commonly observed in skin 
diseases. 

(/) Remitting pain is suggestive and characteristic of colic, neu- 
ralgias, and cramps of all types. 

(g) Pain increased by motion is observed in all inflammatory 
processes, diseases of the bones and joints, and in rachitis and 
scurvy particularly. 

Site of Pain. — The site of the pain usually corresponds quite 

closely with the situation 
of the causative factor. 
This is not always so, and 
perhaps a better way to 
state it would be to say 
that the site of pain de- 
pends upon the nerve dis- 
tribution from the local 
process which causes pain. 
Generally diffused pain 
occurs fairly constantly 
in children with all the 
febrile processes, and par- 
ticularly with those of an 
infectious nature, so that 
its diagnostic import is 
very small. 

Pain in the lateral wall 
of the chest has as its 
most common causes 
pleurisy, intercostal neu- 
ralgia, enlarged bronchial 
glands, vertebral disease, 
pneumonia, and disease and injury of the chest walls. 

Pain in the precordial region is usually due to gastralgia, 
pericarditis (rare in children), angina pectoris, and pseudo- angina. 
Pain about the diaphragm may persist for a time after severe 
vomiting or after prolonged coughing and is commonly present in 
pleurisy. 

Epigastric pain generally depends for its cause upon some one 




Fig. 106.— Epigastric pain. Present most often in 
gastric neuroses, gastric catarrhs, gastric erosions, 
duodenal ulcerations, vertebral diseases, pneumonia 
(commonly) , gastralgia. 



PAIN AS AN EARLY AND PROMINENT SYMPTOM 399 

of the gastric neuroses, gastric inflammation, vertebral disease, or 
pneumonia. 

Pain in the upper extremity is most commonly due to neuri- 
tis, enlarged axillary glands, and bone disease. If confined to the 
left arm, it may be due to enlarged spleen. 

Bilateral pain is usually of central origin or due to disease of the 
vertebra. 

Spinal pain is complained of most often in spinal curvature, 
vertebral disease (relieved by extension), diseases of the meninges 
(is associated with muscular spasm), and is observed in many cases 
of rachitis and scurvy (in which it markedly simulates organic dis- 
ease). 

Pain in the lower extremity is usually due to rheumatism, 
hip disease, psoas abscess, perinephritis, or sciatica. 

Pain referred to the joints may be due to synovitis, osteomye- 
litis, tubercular bone disease, rheumatism, scurvy, or more rarely 
to rachitis. 

Substernal pain is quite characteristic of bronchitis. 

Pain in the ear is almost always due to acute otitis or mas- 
toiditis. 

No attempt has been made to cover all the conditions which 
give rise to pain in various situations, for this would involve the 
use of much space and would be of slight value. All that has been 
attempted has been to refer to some of the most important and 
common causes. 

Pain in the abdomen and headache are two quite important 
symptoms during childhood and are considered in separate parts 
(see "Abdominal Pain," page 123; "Headache," page 312). 

There are, however, some diseases of childhood whose chief and 
earliest symptom is pain, and it is almost invariably that which 
leads us to the discovery of the real trouble; these will be con- 
sidered at this time. 

DISEASES IN WHICH PAIN IS THE EARLY AND PROMINENT 

SYMPTOM 

Acute Otitis. — This is a very frequent disease in children, and one 
which occasions much suffering. It is usually secondary to scar- 
let fever, influenza, acute pharyngitis, rubeola, or diphtheria. The 



4-00 PAIN 

symptoms are very variable, but there are two which are charac- 
teristically constant — pain and fever. 

In the beginning there is generally some nasal discharge, mod- 
erate fever, and slight congestion of the pharynx, but there is noth- 
ing about this condition to lead one to suspect the onset of otitis. 
After two or three days these symptoms subside and the infant 
begins to be very fretful and restless, worrying most of the time 
and occasionally crying out sharply. While the little one is evi- 
dently ill, the cause remains obscure. If the child refuses to allow 
the ear to be touched or refuses to lie upon that side which is affected, 
it is a good indication that otitis is developing. After several 
days a discharge from the ear is noticed, and this at times is the 
first symptom which leads to an appreciation of the real trouble. 
In older children the symptoms are less obscure and pain is usually 
the feature most complained of. It is sharp and severe and comes 
on very early in the attack. 

The usual range of the temperature in an attack of otitis is from 
ioo° to 103 F., and the course is irregular and remittent. Usu- 
ally after rupture has taken place the temperature falls to about 
normal. In older children pain is apparently a more marked fea- 
ture than it is in infants, because they are able to communicate 
the reason of their distress, the ear-drum is tougher and ruptures 
less easily, and the inflammation is usually catarrhal. When it is 
possible to examine the ear, there is redness and congestion of the 
tympanic membrane early in the attack. Later there is either 
bulging of the same or evidences of its rupture. 

The diagnosis is much easier in older children than in infants, 
and particularly on account of the pain which at once directs at- 
tention to the ear. In infancy, however, it may be very difficult to 
make a diagnosis before a discharge from the ear appears. The tem- 
perature is indicative of trouble somewhere, but there is nothing 
about it or the associated symptoms of restlessness, anorexia, or 
the host of other ones which will reasonably suggest a cause. If 
the definite local signs are absent, then the diagnosis is presuma- 
bly made if there be faucial congestion without any further signs 
of throat or lung involvement, the history of a sufficient etiologic 
factor, and the exclusion of other causes of the fever. 

Gastralgia. — This is evidenced by the appearance of sudden 



PAIN AS AN EARLY AND PROMINENT SYMPTOM 401 

and severe gastric pain, and may occur as an accompaniment of 
severe attacks of acute gastric indigestion. Such a pain must 
be at once distinguished from the pain caused by pleurisy, and this 
may require an extended examination. It could hardly be mis- 
taken for the pain which occurs in this situation and is the result 
of spinal caries in the dorsal region, for the latter is less severe and 
of a chronic nature. 

As it is very apt to recur from time to time in children who are 
predisposed to it, the history of previous attacks may be of much 
value. 

When the attack is mild, the pain intermits and there may be no 
other symptoms. When more severe, pallor, cold sweating, and 
considerable prostration may accompany the pain. 



26 



MENINGITIS 

The inflammations which affect the membranes covering the 
brain and the spinal cord may be located in the dura mater (pachy- 
meningitis) or in the pia arachnoid (leptomeningitis), and fre- 
quently the two are existent together. 



PACHYMENINGITIS 

The acute form is very rare in children and usually commences 
as a localized process, extending later to the inner layer. The 
chronic form almost invariably affects the inner layer, and is not 
so rare, although its discovery is usually at autopsy. 

Pachymeningitis is usually dependent upon morbid processes 
in the contiguous bone, so that it is commonly the result of infec- 
tious conditions of the nasal cavity, the middle ear, or the orbit. 

The symptomatology depends more upon hemorrhage than upon 
the inflammatory process, for until hemorrhage occurs the disease 
is rarely distinguished. The onset of hemorrhage is evidenced usu- 
ally by vomiting or by convulsions, or, in case the hemorrhage is 
gradual, there may be simply the occurrence of increasing stupor. 
There may be a large variety of cerebral symptoms which are indef- 
inite, and, generally speaking, pachymeningitis has no definite 
symptomatology apart from the conditions with which it is asso- 
ciated. 

LEPTOMENINGITIS 

The involvement of the meninges in leptomeningitis is general, 
and not localized, like pachymeningitis. According to the position, 
we have several forms, as vertical, basic, posterior basic, ventric- 
ular, spinal, cerebrospinal, and general. If the form is not very 
acute, there is a tendency to localization, but with the acute forms 
diffused processes result. In accordance with the pathology there 
are several varieties recognized — the tuberculous, suppurative, 
epidemic, and syphilitic. 

402 



TUBERCULOUS MENINGITIS 403 

TUBERCULOUS MENINGITIS 

This disease is almost invariably secondary to a tuberculous 
process in some other portion of the body. There are no constant 
features relating to its onset, but when emaciation and general 
weakness have been of long standing in a tuberculous child, the 
onset is very apt to be somewhat rapid. On the other hand, it is 
in those instances in which the child withstands the ravages of the 
disease well that the occurrence of this secondary infection comes 
on rather insidiously and is not expected. As a general thing 
there are more or less ill-defined prodromes which are present 
for a few days or several weeks. 

Traumatism occurring in a tuberculous child seems to have 
some determining element about it, and while we are not able to 
explain just why or how an injury to the head will result in tuber- 
culous meningitis, we cannot ignore an influence which is so pro- 
nounced in so many cases. 

The prodromes are as varied as they are indefinite; there may 
be simply a period of evident but slight illness, and again there 
may be marked apathy, fretfulness, grinding of the teeth at 
night, disturbed sleep, and disinclination to play. The first and 
the last mentioned are the most suggestive ones. 

Vomiting may occur without an adequate cause and without 
preceding nausea, and while such a symptom is indefinite, it is 
very suggestive if associated with constipation and fetid breath. 
So many times when vomiting occurs it is treated as due to some 
digestive disorder, and so often the onset of tuberculous meningitis 
is at first evidenced by vomiting that one should always look 
upon a precipitate or apparently causeless vomiting with much 
suspicion when it occurs during the course of tuberculosis. 

The whole aspect of the child is soon one of evident but indefinite 
illness, with an associated tendency to mental perversion or 
sluggishness, which is unusual to the child. There is a disinclina- 
tion to talk or play, and this may be so marked that errors are 
made in the speech or the words are drawled out with evident 
effort. In other instances there is absolute refusal to speak, to 
walk, or even to stand. Generally the child assumes a frowning- 
expression and may show strong dislike for those whom it has 



404 



MENINGITIS 



previously loved. I regard the change of disposition as of great 
importance. 

As the prodromal symptoms become more pronounced, the 
child may lapse into a condition in which it seems to care for 
nothing, and then cephalalgia is usually a prominent feature. 
Delirium may also occur at this time or an attack of convulsions. 
As the tubercle develops in the meninges before there is much 
inflammation or exudation, we readily see the reason for the 
prodromal symptoms. That is, during the prodromal stage the 

tubercle is developing, but it 
is not until the occurrence of 
the inflammation that the 
disease finally declares itself. 

It is rather difficult to sep- 
arate the stage of active symp- 
toms from the preceding stage, 
as they are merged into one 
another, but at times the sep- 
aration is made unfortunately 
plain by an attack of general 
convulsions. With the ter- 
mination of the prodromals 
the expression of the face 
changes from a frown to a 
vacant expression, which is 
only intensified by the partly 
opened mouth, the staring eyes 
(the child stares as at some 
distant object), and the pupils 
being dilated. It is common to observe some retraction of the 
corners of the mouth. 

The general surface of the body is unusually dry except just 
before death occurs. The position assumed is usually one-sided, 
with a most marked rebellion against the slightest interference. 
As the disease progresses the limbs may become rigid and extended 
and the head retracted, but this latter is usually somewhat tran- 
sient, coming and going. There is invariably a retraction of the 
abdomen. 




Fig. 107. — McEwen's sign. Tympanitic 
note upon percussion over the lateral ventricle 
of the brain. Present in many cases of menin- 
gitis, especially the tubercular type. 






TUBERCULOUS MENINGITIS 



405 



Hydrocephalic cry, which has been looked upon as of so much 
value as a means of diagnosis, is of doubtful value, for it occurs 
frequently in other intracranial affections of childhood. 

Toward the end of the first week of the active symptoms ocular 
phenomena make their appearance, and we may observe all grades 
and varieties of strabismus and ptosis, rolling movements and 
independent movements of the eyeball. Oscillation of the pupils 
is not infrequent. 

Repeated rhythmic movements are common, as champing, 
grinding of the teeth, sucking 
movements, etc. There may be 
also coarse tremors, and particu- 
larly when motion of a limb is 
attempted. While an absolute 
paralysis is rare, partial paralyses 
are common. 

The convulsions which occur 
are either general or may be 
localized, and the usual order is 
first localized convulsions, then 
general convulsions as the ter- 
minal. After the appearance of 
convulsions there may be rigidity, 
for this is the time for such to 
occur, and each convulsion causes 
an increase in the rigidity. Loss 
of sphincter control is the rule. 

There is marked irregularity 
of the pulse very early in the 

prodromal stage, and this irregularity persists. At first there 
may be an increase in the rate, but later it becomes slow with more 
tension. As the disease reaches a terminal period the pulse 
becomes soft and rapid. The respiration is at first rapid, and 
as a rule with some sighing, but later it usually becomes of the 
Cheyne-Stokes type. The temperature is that of tuberculosis, but 
when fever previously existed, the attack evidences a lowering of 
the temperature, and so it may remain low throughout the course 
of the disease. 




Fig. ic 



-Hydrocephalus (side view). 



406 



MENINGITIS 



Tache cerebrale (by drawing the finger-nail along the skin of the 
abdomen there appears, after a few seconds, a distinct red streak, 
which is from one to two inches wide and remains for from three 
to five minutes) is nearly always present, but is not pathognomonic. 
The diagnosis is made early only when one is on the lookout 
for the disease and refuses to accept an apparently causeless 
vomiting as an evidence of digestive disturbance. Naturally 
enough, the cerebral symptoms which are associated with some 

one of the acute gastro- 
intestinal disorders may be 
misleading, but in a child, 
whenever there is a consider- 
able weight of evidence to 
explain the cerebral symp- 
toms, the decision that the 
trouble is tuberculous ought 
to be made with some reser- 
vation. 

It is usual for all of the 

symptoms of the prodromal 

stage to be accounted for 

upon the basis that all are 

due to the constipation which 

is present, but the history of 

the previous condition, the 

occurrence of causeless vomiting without preceding nausea, and 

the influence of a brisk cathartic (failure to relieve) should leave 

one with little doubt. 

When pneumonia is present and meningitis develops during the 
attack, there is a close similarity to tuberculous meningitis, but 
such a combination is unusual, and in doubtful cases the chances 
are in favor of the diagnosis of tuberculous meningitis. The 
bacterial examination of the cerebrospinal fluid is of doubtful 
value, being somewhat uncertain. 




Fig-. 109. — Front view of hydrocephalic infant. 



POSTERIOR BASIC MENINGITIS 
While basilar meningitis is almost always tuberculous, there is a 
chronic form of the disease which is not tuberculous, and this is 



POSTERIOR BASIC MENINGITIS 407 

the disease which is considered at this time. The uniformity of 
the symptomatology makes the diagnosis rather easy. 

The disease occurs almost always during the first year of life, 
and about nine-tenths of all cases occur before the end of the 
first twenty months of life, after the third year the disease being 
exceedingly rare. The onset is somewhat rapid, with the first 
symptoms rather mild, and yet distinctive; these symptoms are : 
(a) retraction of the head ; (b) tonic convulsion ; (c) vomiting. 

Any one of these symptoms will be the first thing to attract 
attention, but no matter which one appears first, the other two 
quickly follow it. Vomiting is the least constant feature of the 
three, but when it occurs, it usually persists throughout the whole 
course of the disease. 

The most characteristic and also the most constant symptom 
is that of head retraction. This may persist for some time in such 
prominence that it overshadows all other symptoms, but it is 
generally associated with tonic spasm. The extensor muscles 
of the neck are first involved, but soon the deeper ones are affected. 
The deep muscles are hard and also tender, and any attempt to 
overcome the spasmodic contracture causes severe pain. In 
the cases that result fatally this contracture persists throughout 
the course of the disease, but gradually subsides if the case goes 
on to recovery, giving way to a very considerable weakness of 
the musculature. 

The tonic spasm consists of head retraction and opisthotonos, 
the latter being extreme, as a rule. Opisthotonos may exhibit 
periods of partial remission, but there is never a complete sub- 
sidence. When the limbs are affected, the spasm may be either 
persistent or intermittent, and as intermittent spasm is generally 
of the flexor type, affecting all the limbs, the position assumed 
is a very much cramped one. Persistent spasm is of the extensor 
type and all the limbs are affected equally. The face may show 
evidences of spasm, so that the expression becomes mask-like. 

Within twenty-four hours of the onset the child becomes lan- 
guid and very irritable, and this persists while the disease lasts. 
Bulging of the fontanelle is common and present early, and is 
generally associated with prominence of the superficial veins of the 
head. This is caused by a moderate degree of hydrocephalus. 



408 MENINGITIS 

Outside of the foregoing symptoms, which are prominent and 
characteristic enough to mark the disease, there may be nystag- 
mus, strabismus of a transient and changing character, champing, 
grinding of the teeth, etc., which are common to many of the 
cerebral diseases of childhood. There is usually a shallow coma 
(irritability alternating with drowsiness) and cerebral group 
breathing (four or five normal respirations followed by long pause, 
then a deep sighing inspiration), which are common to many 
conditions of cerebral depression. 

The pulse is generally rapid or normal, rarely slow, and pupil- 
lary reaction is generally normal. Paralysis is not actually 




Fig. no. — Kernig's sign. The thigh is held at right angles to the body. When an attempt 
is made to extend the leg, bringing it into a line with the thigh, there is either marked resis- 
tance or an inability to extend the leg, if meningitis is present. 



present, but the contractures render the child practically helpless. 
Febrile symptoms are usually entirely absent, but may be present 
in a moderate degree. 

The course of the disease is fairly typical, and the duration is 
from four weeks to five months ; in rare instances it may be pro- 
tracted to one year. 

At first the disease must be distinguished from all other diseases 
which begin with moderate elevation of temperature, retraction of 
the head, and perhaps with vomiting. If, in a child below the age 
of three years, there is retraction of the head which has occurred 
rather suddenly and associated with little or no fever, one might 



ACUTE SUPPURATIVE MENINGITIS 409 

suspect tuberculous meningitis, otitis media, or posterior basic 
meningitis. The fact that there is little or no fever would be 
against a diagnosis of otitis, and an examination of the ear would 
be of immense aid. Usually in otitis, when retraction occurs, 
it is intermittent, while in posterior basic meningitis it is constant. 
In any event, after four or five days the question as to the presence 
of meningitis is definitely settled, but not so as to the type. 

Tuberculous meningitis occurs almost invariably as a secondary 
infection to tuberculosis in other parts; it affects children over 
two years of age, in nearly every instance, head retraction is not 
marked, hydrocephalus is of a different degree, the abdomen is 
retracted, slow pulse is the rule, and the duration is shorter. 
In contradistinction to this posterior basic meningitis occurs 
usually in the first year of life, there is no abdominal retraction, 
head retraction is marked, bradycardia is rare, and the duration 
of the disease longer. The prominence of the opisthotonos in 
posterior basic meningitis is distinctive also. 



ACUTE SUPPURATIVE MENINGITIS 

The causative factors of this disease are many, so that they are 
not always helpful in diagnosis. Among the more important, 
however, are insolation and injury to the head, the extension of 
infective disease of adjacent structures, and particularly suppura- 
tion in the nasal cavity and middle ear, and infective diseases hi 
general, as scarlet fever, smallpox, rubeola, enteric fever, influenza, 
pneumonia, etc. 

The onset of the symptoms is usually very abrupt, and there 
are no prodromes. It is not reasonable to look upon the manifes- 
tations of the antecedent disease as prodromes, for they have no 
connection with the meningitis except as the disease acts as an 
etiologic factor of it. 

Generally there is a severe convulsion or a severe rigor, which 
is almost immediately followed by high elevation of the tempera- 
ture. Headache is soon intense, and usually associated with 
photophobia and irritability, and these are soon followed by 
delirium, which is sometimes very violent and soon lapses into a 
coma, about the third day. Vomiting and constipation arc the 



4IO MENINGITIS 

rule. If the disease occurs in a child with open fontanelle, then 
this becomes markedly prominent. 

During the occurrence of coma, which generally lasts from the 
third day until death, which is usually before the eighth day, 
other symptoms make their appearance, and these are the signs 
which are generally present in other forms of meningitis, as 
retraction of the head, general extensor rigidity, champing and 
sucking movements, grinding of the teeth, irregular movements 
of the eyes, strabismus, etc. Pulse and respiration are both rapid 
throughout the course of the disease, and toward the end become 
irregular. 

While there can be no clear clinical distinction made between 
stages of this disease, yet one must be struck by the fact that there 
is a more or less well-defined stage of irritative phenomena and 
one of paralytic symptoms. 

The whole clinical picture is so plain that the diagnosis offers 
no difficulty except in those cases in which the meningitis occurs 
during the course of some severe adynamic condition, and under 
those circumstances the severe symptoms of the onset are very 
apt to be absent, and the gradual development of the paralytic 
symptoms are our only guide. As these are somewhat modified 
by the symptoms of the antecedent disease, the difficulty is at 
times great. But by recalling that this form of meningitis may 
occur during the course of any of the severe general infections, 
one is forewarned in regard to cerebral symptoms which are not 
accounted for in some other way. 



EPIDEMIC CEREBROSPINAL MENINGITIS 

The occurrence of this disease has almost invariably been during 
periods of mild weather which closely follow cold which has not 
been excessive. The outbreaks of the disease are usually simul- 
taneously in remote regions and without any regard to the routes 
of travel, the food-supply, or the water. The symptoms are far 
from being constant, each epidemic showing marked variations 
and each individual epidemic following no regular type. 

Preceding the onset of the disease there may at times be a period 
of one or two days in which indefinite symptoms of headache, 



EPIDEMIC CEREBROSPINAL MENINGITIS 411 

general malaise, and rigors are more or less prominent. Following 
this prodromal period, which may be entirely absent, there is 
the sudden occurrence of vomiting or convulsions (sometimes of 
both), intense headache, and high elevation of temperature (103 
to 105 F. or more). The pain soon spreads from the head, going 
down into the back and to the limbs, and this is usually accom- 
panied by a general hyperesthesia. Associated with these 
symptoms there is generally a marked restlessness, which is later 
followed by delirium and finally coma. 

Rigidity of the neck musculature is marked ; the head is retracted 
and opisthotonos is usually present. The respiration is slow and 
irregular and the pulse weak (it may be either slow or rapid). 
The eyes are almost invariably suffused early in the disease, but 
later on destructive panophthalmitis is common. Cutaneous 
eruptions are not infrequent and may be in the form of erythema, 
herpes, or more commonly petechial spots. 

These symptoms may cover a course of from two to ten days or, 
in rarer instances, the disease may be protracted for several weeks, 
and while the disease is running its course, recovery or death may 
occur somewhat unexpectedly at any period of the disease. 

If recovery takes place early, it may be complete ; but if it is 
delayed for days, then there is almost always some permanent 
disability of the eyes, of hearing (from a destructive otitis media), 
of motion, or of sensibility, so that many times the child is left 
in a crippled condition or both blind and deaf. Convalescence, 
in any event, is very tedious. 

The two fatal forms of the disease are the hemorrhagic (evi- 
denced by the occurrence of cutaneous and other hemorrhages) 
and the adynamic (with sudden onset, rapid collapse, and cardio- 
vascular depression which may prove fatal within twelve hours). 
The adynamic cases are difficult of diagnosis except in the presence 
of an epidemic. The fact that an epidemic is raging is of great 
importance in the early recognition of the disease, and most 
important of all is the discovery of the specific germ in the cerebro- 
spinal fluid. 

The greatest difficulty in early recognition will be encountered 
in the presence of an epidemic of one of the acute infectious 
exanthemata being prevalent at the same time, but such errors 



412 MENINGITIS 

may be avoided by a careful consideration of the prodromes, 
which are fairly typical in these diseases, and the appearance of 
the characteristic eruption. 

Pneumonia may readily be excluded by the physical signs or by 
a bacterial examination of the cerebrospinal fluid. There is no 
preceding history of tuberculosis, the attack is more acute, more 
severe, and more painful, than in tuberculous meningitis, and 
that helps to distinguish these two. 



THE TEMPERATURE 

Previous to taking up a consideration of an elevation of the 
temperature it will be well briefly to speak of chills. 



CHILLS 

These may vary in intensity, so that in the mildest form they 
are evidenced as "creeping" feelings running up and down the 
spine, or they may exist as true rigors, in which the child shakes 
violently for a half hour or even more. In infants and very 
young children a chill is not common, its place being usually taken 
"by a convulsion, which in that particular has the same significance 
as the chill of the older child. 

Clinically, a chill indicates the onset of some severe infection, 
and the severity of such infection cannot be judged by the severity 
of the chill; a slight chill may announce the onset of a severe 
infection, and vice versa. Again, a chill (of some degree) is an 
essential symptom of some diseases, as malaria. Occurring dur- 
ing the course of certain diseases, a chill indicates some com- 
plication or further extension of the process; as in typhoid, it 
suggests a secondary or a mixed infection. 

If chill is associated with profuse perspiration and this is fre- 
quently repeated, it is indicative of pyemia, septicemia, or some 
purulent inflammation. Chills from depressing drug action and 
from nervousness are uncommon during childhood. 

FEVER 

The body-temperature of the child is maintained uniformly at 
about 98. 6° P., and this is due to the control exercised by the 
central regulating apparatus. When for any reason this ther- 
motaxic mechanism is interfered with, there is a disturbance in 
the stability of the temperature, and fever, which is an elevation 
of the temperature, is the result. 

413 



4 i4 



THE TEMPERATURE 



The estimation of the temperature in the child should never be 
attempted by the sense of touch, for this is a most deceptive and 
unsatisfactory method. The proper use of a clinical thermometer 
is an absolute necessity. The temperature is best taken by the 
rectum in children, as it is a more exact method. That is, it is 
more exact if it is properly performed ; it is uncertain if the ther- 
mometer is plunged into the rectum for one or two inches, as is 
usually done, and then left there for a time. By such means one 
is never certain that he has not buried the end of the thermometer 




Fig. in.— Method of taking the rectal temperature of an infant or young child. 



in a mass of feces, which would give an incorrect result. The 
instrument should be slowly introduced at least for two inches, 
and then, while it is retained in the rectum, it must be very slowly 
withdrawn for an inch and again pushed in, and this procedure 
kept up for a sufficient time to obtain a correct registration (which 
latter depends upon the thermometer). 

If for any reason the rectal method is unavailable or undesirable, 
the temperature may be taken in the axilla, but to insure accuracy 
certain precautions must be observed. The axilla must be dried 



FEVER 415 

thoroughly, and the thermometer must be accurately placed in 
the arm-pit and not with the bulb beyond the posterior fold of 
skin (as is often done). After the instrument is placed, the arm 
should be carried across the chest in an easy manner and retained 
there by some one other than the patient; this is necessary, be- 
cause if the arm is held rigidly, it creates a hollow in the arm-pit, 
and when the thermometer rests in this, the result is not accurate. 

Taking the temperature by the mouth in children is as uncertain 
as it is unnecessary. 

In estimating the temperature it must be remembered that 
the rectal method of taking it gives a result which is normally 
four-fifths of a degree higher than that which would be obtained 
by the mouth, and which is usually taken as the standard, and an 
axillary temperature is close to one degree lower than that of the 
mouth. 

The daily variations of the temperature which are physiologic 
are not of sufficient importance in diagnosis to warrant their 
discussion in this place. 

Symptoms of Fever. — We will first consider the general symp- 
toms and then take up some more in detail. 

In children fever is evidenced, at first, usually by a disinclina- 
tion to prolonged play or activity, by unusual thirst, fretfulness, 
accelerated pulse, coated tongue, highly colored urine, and perhaps 
a flushed appearance of the face. With these symptoms present 
an examination shows that the temperature is elevated. 

The elevation of the temperature is not the only evidence of 
fever, however. Wasting of the solid tissues is a very marked 
symptom, and is observed even in a moderate fever, provided it 
extends over a protracted period. While the solid tissues waste, 
the fluids of the body also are diminished in amount, and this is 
the chief reason why we observe glandular disturbances in the 
course of fever. The reduction of the fluids also accounts for the 
occurrence of increased thirst, the loss of appetite, and the diges- 
tive disturbances which are usually present. Diminution in the 
amount of urine and its concentration and constipation are all 
due to the same cause. 

Increased pulse-rate is the rule in pyrexia, and is in all proba- 
bility directly due to the increase in the temperature, but this 



416 THE TEMPERATURE 

may be influenced by other conditions. For instance, in menin- 
gitis the pulse may be characteristically slow in relation to the 
height of the fever, while in diphtheria and other diseases in 
which fever is the rule there may be a markedly' accelerated 
pulse-rate, but absence of fever. 

Increased respiration is the rule and is much more constant 
than increased pulse-rate. 

Diagnostic Significance of Fever. — The presence of fever is 
diagnostic in that it generally excludes hysteria, and in many 
other diseases (as, for example, convulsions, which is a common 
syndrome of childhood) it largely influences the conclusions. 
These are all discussed under the appropriate headings. When 
fever is present in the child, it implies that there is a disturbance 
between the normal relations of heat production and dissipation. 
This may be occasioned by an infarction, an intoxication, a 
cerebral lesion, or some peripheral irritation. 

There are several reasons why the occurrence of an elevation 
of the temperature is not of as much diagnostic significance in 
the child as in the adult : 

(a) The heat-producing centers are more easily excited, on 
account of the immaturity. 

(6) The heat-controlling centers show a similar immaturity, 
and as a consequence there is a weaker control. These two 
foregoing conditions in the child account for the occurrence of 
high temperatures from apparently very trivial causes. 

(c) The heat-dissipating apparatus or mechanism is very much 
more active than it is in the adult, and this accounts for the 
variability of the temperature during most diseases. 

Causes of Fever. — These may be predisposing and exciting. 
Of the former, we encounter a neurotic inheritance and chronic 
states of malnutrition, both of which interfere with the perfect 
mechanism of the heat centers at the base of the brain. 

Of the exciting causes, the most important are the infections, 
whether local or general, the vast majority of which are now 
recognized not so much by the inflammation which is produced, but 
as being dependent upon the presence of microorganisms in the 
inflamed part, from which toxic materials enter the general 



FEVER 



417 



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Fig. 112.— Represents a hectic and suppurative 
fever type, which is generally accompanied with sweat- 
ing. 



circulation, producing fever by a direct action upon the thermo- 
genic centers. 

All infectious diseases without local inflammatory lesions are 
also recognized as exciting causes of fever. The autointoxications 
are not so important 
in childhood as in adult 
life, being less common. 
If a cerebral lesion 
(tumor, thrombosis, 
etc.) involves the cen- 
ters controlling heat 
production and heat 
dissipation, disturb- 
ances of the tempera- 
ture will result. Direct 

exposure to external heat, as in insolation, will produce fever, 
and as insolation in infants is always accompanied by more or 
less intestinal disturbance with fermentation, a toxic element is 
added which tends to keep up the pyrexia. 

In very young or very delicate infants the application of external 

heat will at times pro- 
duce an elevation of 
the temperature which 
is seemingly out of all 
proportion to the cause. 
Peripheral irritation 
will readily produce py- 
rexia in a poorly nour- 
ished infant, and ex- 
amples of this are 
commonly observed in 
the fever which is associated with the difficult cutting of the 
teeth, the presence of undigested food in the intestinal tract, or 
foreign bodies, such as intestinal parasites. 

Significance of the Type. — For the reasons already stated. 
the height of the fever in children is not of considerable impor- 
tance, and when compared with similar intensity in the adult, 



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Fig. 113.— Represents a continued fever. It is ob- 
served mostly in erysipelas, acute tuberculosis, lobar 
pneumonia, and typhoid fever. 



27 



418 



THE TEMPERATURE 



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Fig. 114.— Represents intermittent fever. The left 
hand half showing the quotidian type, while the right 
hand half shows the tertian type. It is significant of 
malaria. 



its relative unimportance is very marked. The type of the fever 
is of far greater importance in diagnosis than the intensity. 

Continued Fever. — This is evidenced when the pyrexia con- 
tinues for forty-eight hours or more and when the daily difference 
between the maximum and the minimum temperatures is not 

more than two degrees 
Fahrenheit. It is ob- 
served in erysipelas, 
acute tuberculosis, lobar 
pneumonia, and typhoid 
fever. In lobar pneu- 
monia it is particularly 
characteristic, suddenly 
reaching a high degree 
and continuing with 
little variation for 
several days, until the 
crisis occurs, when the temperature becomes normal or sub- 
normal. In acute tuberculosis, more than in any other con- 
dition, there is long-continued fever. 

No case of typhoid fever ever occurs in the child without fever ; 
during the first four or five days the temperature shows a pro- 
gressive rise, with morn- 
ing remissions and early 
evening exacerbations 
until the acme is reached 
(which is usually about 
io4°F.). Then the tem- 
perature remains nearly 
stationary (slight morn- 
ing remissions and even- 
ing exacerbations) until 
the middle of the sec- 
ond or the beginning of the third week, when lysis occurs. 
Intermittent Type. — This is evidenced by the rise of tempera- 
ture being followed by a fall which is to or slightly below normal, 
and the same occurring periodically. The typical intermittent 
type is observed in malaria. It is simulated by certain cases of 



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Fig. 115. — Represents the remittent type. This is 
suggestive of one form of malaria, of tuberculosis (not 
acute), and suppuration. 



FEVER 419 

typhoid, tuberculosis, and in suppuration, when the pus is con- 
fined. The distinction from malaria can be readily established 
by an examination of the blood; if the plasmodium malariae is 
found, it is positive evidence of malarial infection. 

Remittent Type. — This is characterized by a persistency of 
more than forty-eight hours, but with a difference between maxi- 
mum and minimum temperatures of more than two degrees Fahr- 
enheit. Such a type is characteristic of one form of malaria, but 
may occur at any time during the course of any disease which is ac- 
companied by fever, and particularly if it be of an intermittent 
type. This type of fever in children is peculiarly significant of 
tuberculosis (except the acute form) and of suppuration. It may 
be simulated by a continued fever which is subject to marked re- 
missions shortly following the use of antipyretic measures, and 
this possibility must be thought of. 

Subnormal Temperature. — This occurs independently of py- 
rexia and is the usual sequel of protracted pyrexia and condi- 
tions accompanied with marked wasting of the tissues. During 
the course of a fever it may indicate that a crisis has been reached, 
or may be due to an accident or to complications. Occurring at 
the expected time, it indicates a crisis; occurring at any other 
period during the disease, it is suggestive of complication or 
accident. 



ENTERIC FEVER 

Of the essential symptoms of typhoid fever, the most important, 
as regards diagnosis, is the temperature which is invariably 
present. No case of typhoid fever is ever present in the child 
without an elevation of the temperature, and, further than that, 
the course and the duration of the fever are such that in most 
instances the diagnosis is much simplified, even when the other 
symptoms are not strongly indicative. 

Preceding the onset of the febrile period of the disease there 
are usually several days during which the little one exhibits 
indefinite symptoms of general malaise, anorexia, and restlessness, 
all of which lead one to the conclusion that the child is not well, 
but which do not allow of a definite diagnosis. Occasionally, 
however, one will encounter cases in which the most carefully 
taken history will fail to reveal anything unusual preceding the 
rather sudden onset. These latter instances are not the common 
ones, but occur frequently enough to leave one with nothing about 
the onset of the disease which is at all suggestive ; it may be gradual, 
or may occur more suddenly, with vomiting, rapid pulse, and 
sometimes with a convulsion. 

Profuse perspiration, herpes of the face, and a temperature 
which shows a complete remission, taken singly as symptoms at 
the onset of a disease, are strongly against a diagnosis of typhoid. 
On the other hand, epistaxis and a temperature which shows a 
steady rise and is uninfluenced by the administration of anti-. 
pyretics (particularly quinin) is very suggestive of typhoid fever. 

It may be well to mention the fact at this point that the use of 
the internal antipyretics at the onset of typhoid fever (and fre- 
quently during its course also) in children very commonly results 
in a slight elevation of the temperature, which is noticeable a 
few minutes after the administration of the same. 

With nothing suggestive about the onset the danger is in 
mistaking the symptoms as evidences of other diseases. The 
most frequent error is in diagnosing the case as one of acute 

420 



ENTERIC FEVER 42 I 

indigestion, for at this period the only means that we have of 
differentiating the two is the history (of some definite etiologic 
factor in indigestion, and of infection in typhoid) and the fact 
that in typhoid fever the quickened pulse, which is out of all 
proportion to what we would naturally expect in the presence of 
such a temperature, is a very early occurrence, as is also splenic 
enlargement. 

Now, in regard to the latter, while it is usually a very early 
accompaniment of typhoid fever, it is by no means constantly 
so, nor is the enlargement ever as prominent a feature as in adult 
life. It is generally possible to map out the enlarged spleen by 
palpation after the second or third day of the disease, but later it 
becomes much more difficult, for by the end of the first week the 
tympanites may interfere with the examination. To be of real 
diagnostic value the splenic enlargement must be of recent occur- 
rence; that is, we must be satisfied that it was not present for 
some time previously. Too much stress has usually been placed 
upon the value of this symptom, but I have found that, in my 
cases, in about 50 per cent, it is not demonstrable after moderate 
tympanites occurs, and in a large proportion of the cases one 
is not positive of its recent occurrence. 

Naturally without a very clear history and a very typical 
course one would not diagnose typhoid fever in a child under 
three years of age, and considerable doubt would exist, under like 
circumstances, in a child who was under six years. 

During the first four or five days of typhoid fever the tempera- 
ture shows a progressive rise, with remissions in the morning and 
exacerbations in the late afternoon or evening, until the acme is 
reached. The morning remissions are generally within two 
degrees Fahrenheit. 

After this period, the temperature having reached its acme, it 
remains at this height with slight morning remissions and evening 
exacerbations which are not marked, so that the difference between 
the highest and lowest daily temperatures is well within one and 
one-half degrees Fahrenheit. Such slight remissions occurring 
during the second week of the disease are quite typical, and are 
probably due to the fact that ulceration is not as frequent nor as 
extensive in the child as in the adult. From the middle of the 



422 



ENTERIC FEVER 



second or the beginning of the third week termination by lysis 
begins to evidence itself. 

In very young children the fever runs a course of from eight 
days to fourteen days, and before the age of ten years a longer 
course is infrequent. After the tenth year of life the disease in 
all its particulars more closely approximates the adult type. 

During the first six or seven days of the disease the general 
symptoms are so variable in young children and so misleading 
that it is almost impossible to make a diagnosis of typhoid fever 
except by exclusion. The character of the temperature is of 
most importance in the recognition of the disease, so that we first 
exclude all local causes for the elevation, and this still leaves us 





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Fig. n6.— Chart of the temperature ( ) and pulse ( ) in typhoid fever of moderate 

severity in a male child five years old. 



in doubt as to which of the infectious processes is present. After 
the third day it is usually possible to exclude, without any doubt, 
the acute infectious exanthemata, for the characteristic eruptions 
are absent. In the same manner cases of influenza (especially 
that type which has slight catarrhal symptoms), by the short dura- 
tion of the active symptoms, are readily excluded. 

Symptoms which are referable to the nervous system are very 
apt to be more prominent in children than intestinal symptoms, 
and this leads to many an error in diagnosis. The more common 
nervous symptoms which are present in adults (subsultus tendi- 
num, coma vigil, dry glazed tongue, carphologia) are absent in 
children. Of all the nervous symptoms which are present, 
cephalalgia and mild delirium are the most constant in childhood, 



ENTERIC FEVER 



423 



and are particularly marked during the night. The very young 
child is usually dull or in a state of semi-stupor. There may 
be hyperesthesia, opisthotonos, unequal or contracted pupils, 
strabismus, etc. Such symptoms may suggest meningitis. 

Between tuberculous meningitis and typhoid fever the differen- 
tiation may at times be difficult, but such difficulty will only be 
short-lived, as the differences are soon well marked. Probably 
much of the difficulty is occasioned by the fact that tuberculous 
meningitis is thought of more often than is typhoid fever. The 
chief difference exhibited by tuberculous meningitis is that it 
usually runs its course with little fever and almost invariably 
begins with an attack of vomiting, which is repeated upon several 





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Fig. 117.— Chart of the temperature ( ) and pulse ( ) in typhoid fever in an infant 

of seventeen months. This case was one of four in the same family, the splenic enlargement 
and eruption being marked in all. 



successive days. Then, again, cephalalgia is more or less severe 
and constant in meningitis, so that if the vomiting and the head- 
ache are prominent and continued symptoms, tvphoid fever 
may reasonably be excluded. 

After a few days (four to six) meningitis becomes much more 
pronounced in its symptoms, leaving much less room for doubt as 
to the cause; the pulse becomes abnormally slow and irregular. 
the child becomes somnolent, and the abdomen is either sunken 
or flat. 

A true difficulty is encountered in those rare cases in which 
tuberculous meningitis runs its course for several days with little 
or no appreciable cerebral symptoms. Such cases arc no doubt 



424 ENTERIC FEVER 

due to an acute miliary tuberculosis with subsequent involvement 
of the meninges. 

It is in these cases that splenic tumor and the presence of rose 
spots of typhoid fever are such welcome aids to the diagnostician. 

In the absence of these, then, the symptoms must be considered 
carefully one by one, and the etiology and previous history are 
of great import. 

While ulcerative endocarditis very closely simulates typhoid 
fever, as a matter of diagnosis it does not cause much concern 
because of its rarity in childhood. There is an associated splenic 
enlargement and also a discrete eruption which is quite similar 
to that observed in typhoid fever. The temperature, however, 
is markedly of that type which accompanies ulcerative processes 
generally (marked remissions, chills, and profuse perspiration). 

The demonstration of splenic enlargement is not of great value 
in the diagnosis of typhoid, although in the differentiation from 
other diseases it has a distinct value at times. Of much greater 
import is the eruption of typhoid rose spots, but even this symp- 
tom is only present in about 60 per cent, of the cases and is very 
much less characteristic than in adults. The spots are a palish 
pink, slightly elevated, and disappear under pressure. They are 
about the size of the head of a pin and are not abundant in num- 
ber. Their appearance takes place between the sixth and eleventh 
day, as a rule, upon the abdomen, chest, and back, and more 
rarely upon the limbs. Bach spot persists for about three days, 
but as they appear in successive crops, the entire period during 
which they are in evidence is several days. 

The condition of the bowels is never a criterion of the severity 
of the infection (as is so often supposed), and in most cases diar- 
rhea is not present, and when it is, it is of a mild type, from two 
to four stools being the daily average in the child. There is noth- 
ing about the stool itself which is at all characteristic. Tympan- 
ites is rarely extreme, and is usually only present in a moderate 
degree. 

When the attempt is made to differentiate typhoid fever from 
an acute miliary tuberculosis, much difficulty may be experienced 
at times, but this is considered under another section (see page 
434)- 



ENTERIC FEVER 425 

Value of the Widal Test in Typhoid Fever. — This test depends 
for its existence upon the property of the blood-serum of a patient 
suffering from typhoid fever to cause an agglutination of the 
bacilli, when added to a fresh bouillon culture of the bacilli, so 
that they sink as a rather flocculent precipitate. It is not always 
present, even in undoubted cases of enteric fever, so that its value 
is much decreased. There are on record several instances in 
which repeated attempts resulted in a negative result of the test 
and the subsequent autopsy gave evidence of undoubted typhoid 
fever. 

Then, in persons who have once had the disease, for an indefinite 
period, which differs with the individual, there exists in the 
blood-serum the property of giving the reaction, even without 
the presence of any evidence of ill health. The value is further 
lessened by the fact that it is not possible to obtain the desired 
result early in the course of the disease, but only well along into 
the second week, and rarely before the seventh day. Usually 
before this time the diagnosis has been made. 

Value of the Diazo Reaction. — This reaction of the urine, 
which may be demonstrated to some extent in cases of typhoid 
fever, is of even less value in the diagnosis than the Widal test, for 
it is much more apt to be absent. Another feature which destroys 
its utility markedly is its undoubted presence under other con- 
ditions. There is no disease in which the reaction is so marked 
as in rubeola, just about the time of the appearance of the cutane- 
ous eruption. 



MALARIA 

There is but one thing that is at all certain in malaria as it 
is exhibited in infants and young children, and that is its periodic- 
ity. There may be any one or a combination of several indefinite 
symptoms, which may point toward some other condition being 
the cause, and none of them particularly indicative of a malarial 
infection; but if out of this diversity of symptomatology there 
is anything which shows a periodicity, then malaria should at once 
be suspected as the cause. 

Because of this variableness, it is almost impossible to give a 
fair description of the disease, and all that can reasonably be done 
is to give the symptomatology of a somewhat typical case, with 
emphasis upon the fact that it is typical and should not mislead 
one into the error of expecting just such conditions to arise in any 
given case. Diversity of symptoms and periodicity are the two 
strong diagnostic features of malaria, and these are corroborated 
by an examination of the blood for the plasmodium. 

The incubation period of the disease has become quite well 
established as being fourteen days. During this period there 
are no symptoms which are at all suggestive, and when present 
at all, they are indefinite ones of anorexia, lassitude, and some 
slight gastric disturbance. When the attack itself is developed, 
then the symptoms are usually divided into well-defined stages 
if the child is over the age of seven years. Under that age, uncer- 
tainty rules. 

In children over seven the first stage is "the cold stage," which 
generally begins with a sensation of great lassitude and some 
headache, and perhaps a decided chill and vomiting. At this 
time the appearance of the child is somewhat peculiar, in that 
the temporal grooves appear to be sunken, the nose looks pinched, 
and the eyes are deep set, with darkened borders. The skin is 
usually very pale and the feet and hands cold and the nails blue. 

This stage is almost immediately followed by the "hot stage," 
which is evidenced by the onset of high temperature (104 to 

426 



MALARIA 



427 



106 F.), which persists for from four to twelve hours, with a 
gradual fail, which is generally to normal. The constitutional 
symptoms are not in proportion to the height of the fever, being 
much milder than one would look for with such an elevation of 
temperature. During this stage the skin, which has been pale, 
becomes markedly flushed, but remains dry, and this is associated 
with dryness of the mucous membranes of the mouth, resulting in 
an intense thirst. 

Then follows the "sweating stage," in which the skin, which 
was previously dry and hot, becomes gradually moist, until 
finally a rather profuse acid perspiration covers the whole of the 
body. This moisture is first noticed upon the forehead and in 



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Fig. 118. — Tertian type of malarial fever. Male child of six years. Quinin begun at X. 



the axilla. If the subjective symptoms have not entirely abated 
or decreased in severity during the early part of the hot stage, 
they do so at this period, so that there is a complete subsidence of 
all such symptoms. Sometimes the manifestations of the sweat- 
ing stage are so slight that there is danger of its being overlooked. 
It usually lasts somewhat longer than either of the preceding 
stages. 

With the complete subsidence of the paroxysm there is usuallv 
a quiet, restful sleep, from which the child awakens refreshed 
but visibly weakened. Then there may follow a period of several 
hours or longer, when a second paroxysm occurs. It is according 
to the length of this interval between the paroxvsms that we 
recognize the following types of the disease: Quotidian, recurring 



4 2i 



MALARIA 



every day; tertian, with an interval of one day in which there 
is an entire absence of symptoms; quartan, with an interval 
of two days, the paroxysm occurring on every fourth day. 

As has already been stated, the irregular forms of the disease 
are the most frequent among children, and particularly those 
who are under seven years of age. As would be expected, con- 
sidering the irritability of the child's nervous system and its 
immaturity, the commonest type is that which has its chief 
symptoms exhibited through that system. In such masked forms 
headache is usually a marked feature, and is associated with more 
or less drowsiness and gastric disturbance, so that under certain 



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Fig. 119.— Quotidian type of malarial fever. Female child of eight years. Quinin begun at X. 



circumstances it may lead one to suspect the presence of tubercu- 
lous meningitis. 

In other instances, and this is particularly true of infants, the 
congestion which accompanies the paroxysm may be so acute 
and severe in the lungs that, giving rise to obscure symptoms, 
an error in diagnosis is readily made. Pain referred to various 
portions of the body is not uncommon, and epigastric pain may 
mark the onset of a paroxysm. 

And so I might go on, and recite instance after instance of the 
frequency of irregular forms and of obscure symptoms. It is 
sufficient, however, to state that two things are needful, and are 
also sufficient, for the diagnosis of malaria in children under seven 
years (and many over that age) : periodicity and the subsidence 
of all symptoms under proper anti-malarial treatment. Demon- 
stration of the plasmodium in the blood of the patient is a valuable 



MALARIA 429 

aid, but not a necessary one, a negative result not excluding the 
disease. 

Disregarding the general symptoms, which may take many forms, 
I shall proceed at once to a consideration of the means which we 
have at hand for making a correct diagnosis. These will be consid- 
ered in the order of their relative importance. 

(a) Demonstration of the plasmodium malariae in the blood. 
When this is present, the diagnosis of malaria is positively made. 
The plasmodia may be few in number, so that, whenever possi- 
ble, the blood which is to be examined should be drawn just pre- 
vious to or during the febrile stage of the paroxysm (if such exists), 
and the extra precaution should have been observed that no anti- 
malarial treatment was given for at least seven hours preceding 
the time of the withdrawal of the blood for examination. The 
examination must be undertaken by one who is experienced in the 
technic of such work, because the possibility of obtaining a neg- 
ative result from faulty manipulation is very large. Even in the 
hands of the experienced it is difficult at times to demonstrate the 
presence of the plasmodium, so that a negative result is by no means 
conclusive, for the means of overcoming all the difficulties which 
influence the examination are not always at hand. Many times 
the blood examination is not practicable, and reliance must be 
placed upon other things, which are considered below. 

(b) Periodicity of the manifestations : In the very young the 
occurrence of a well-marked intermittent fever is the great excep- 
tion, most of the cases assuming an irregular intermittent type. 
The masked and irregular forms simulate so many different diseases 
and are so misleading that no matter what the manifestations may 
be in a given case, if there is a distinct periodicity about them, one 
is warranted in being strongly suspicious of malaria. That such 
a periodicity depends upon malarial infection should be proved or 
corroborated by the administration of the anti-malarial treatment 
and the effect noted. 

(c) The prompt effect of the administration of an anti-malarial 
treatment. Ouinin has but little, if any, effect upon fevers which 
are not malarial, and, on the other hand, if it is properly admin- 
istered, the fevers which are immediately and permanently con- 
trolled by its use are of malarial origin. Such a therapeutic tost 
then becomes very valuable in all doubtful cases with obscure 



43 O MALARIA 

symptoms. It is not sufficient simply to administer it there must 
be a reasonable certainty that it is absorbed. 

(d) Splenic enlargement : Too much emphasis has been usually 
laid upon the value of enlargement of the spleen in the diagnosis of 
malaria in children. Such an enlargement occurs in many of the 
disorders of infancy and of childhood. At times it is very difficult 
to demonstrate, being present but in a slight degree. As an aid to 
the diagnosis of malaria its value is practically nil, unless associated 
with it there are manifestations of periodicity. 

(e) Exposure to infection: In a primary attack, if the history 
showed that the child had been exposed in a malarious district, 
such information might be of some small value. On the other 
hand, if there have been previous attacks, and with similar symp- 
toms, then such information is of great value, on account of the 
marked tendency of the disease to recur. 

In subacute forms of the disease the most marked feature is the 
anemia. Splenic enlargement is also usually marked. The rise 
of temperature may be very slight and so variable that the ther- 
mometer must be used several times daily to discover its presence. 
These, with the general symptoms, may be accounted for by the 
anemic condition, so that one is only justified in making a positive 
diagnosis of malaria by the demonstration of the plasmodium in the 
blood, or by the effect upon the symptoms of the therapeutic test. 

The chronic forms may at times simulate tuberculosis when the 
latter occurs with indefinite symptoms and no discoverable local 
lesions. Here is where a clear history is very important, both as 
regards the family and the occurrence of previous disease. The 
absence of splenic enlargement and the absolute failure of an anti- 
malaria treatment immediately to improve the condition would at 
once eliminate malaria as the cause. 

Pyemia may exist, with the pus collecting in a cavity or in a par- 
enchymatous organ, so that for a time all local signs are absent, 
and the fever and indefiniteness of all the symptoms may lead to a 
suspicion of malaria. Suppurative bone disease may for a time 
exhibit a similar picture, and particularly in infants who cannot 
complain of definitely located pain. A thorough physical exami- 
nation in both of the above instances should remove most of the 
doubt, and this may be supplemented by the therapeutic test. 



TUBERCULOSIS 

This infectious, communicable disease, which was at one time, 
and not long since, considered rather a rare occurrence in infancy 
and early childhood, now occupies a large place and an important 
one in pediatric study and in infant mortality. 

A predisposition to the occurrence of the disease may be local 
or general. A local predisposition is caused by any pathologic con- 
dition of the parts which are exposed to infection, as repeated 
attacks of bronchitis, the presence of adenoids and hypertrophied 
tonsils, etc. Certain diseases also are more liable than others to 
be followed by some tuberculous process, as is observed in rubeola, 
pertussis, and influenza. 

No organ of the body is exempt, and several organs may be the 
seat of the disease at the same time. The bacillus gains entrance 
to the body by various routes, even at times passing through 
the placenta of the mother to the child in utero. However, 
most of the infection is air-borne. It is not important that 
these points be dwelt upon, as they are not within the scope of this 
work, and besides they are ably and elaborately discussed in 
nearly all works upon the disease. What concerns us more for the 
purposes of diagnosis is the varieties which are seen at the various 
ages of life. 

During the first two years of life the disease occurs almost uni- 
formly as an affection of the bronchial lymph-nodes and of the 
lungs, and in such cases the cause of death is usually pulmonary 
tuberculosis ; more rarely the cause is tuberculous meningitis. The 
latter is rare, however, except as it occurs as a secondary condition 
to the pulmonary infection. 

After the period of infancy has been passed, tuberculous men- 
ingitis which is unassociated with pulmonary involvement is more 
common, and so much so that between the beginning of the third 
year and the end of the fourth year it is a frequent cause of the 
deaths from the disease. 

From the end of the second year tuberculosis of the bones, of 

43 t 



432 



TUBERCULOSIS 



the mesenteric lymph-nodes, of the peritoneum, and of the intes- 
tines is not uncommon as a primary affection of these parts, al- 
though other portions of the body do not escape the ravages of the 
affection. 

There is a very marked diversity in the early symptoms of tu- 
berculosis, and this diversity is influenced largely by the peculiar 
constitution of each individual, the source and also the extent of 
the infection. Like many other things in medicine, by inocula- 
tion experiments we are able 
to prove that there is an incu- 
bation period in this disease, 
but when it comes to a ques- 
tion of the practical applica- 
tion of that fact, we are help- 
less; clinically, we are unable 
to define or establish it. The 
general symptoms are in most 
cases unrecognized until the 
local ones appear. 

The best method of the early 
diagnosis is the recognition of 
the tuberculous diathesis and 
the application of auscultation 
of the inspiration. In auscul- 
tation of the inspiration there 
should be no differences be- 
tween the right and left side. 
I firmly believe that if we 
were more skilled in the art 
of auscultation and our ears 
trained to appreciate slight differences, more early diagnoses would 
be made of this white plague. 

There are, however, peculiarities which distinguish the disease 
from the other infectious fevers : it has a marked tendency to be- 
come chronic; it produces characteristic lesions in the various 
organs and parts of the body that are invaded. 

The disease is generally characterized by a progressive loss of 
flesh and strength, which is not so noticeable at first, but which in 




Fig. 120.— Showing the situation of fine 
crackling rales which are heard upon or after 
coughing and at the end of inspiration in the 
early stages of pulmonary tuberculosis. 



TUBERCULOSIS 



433 



the later stages is very marked. Night-sweats are common, be- 
ginning toward the time of night when the temperature falls. 
Then there are usually marked evidences of anemia, of more or less 
intestinal disorder, and of fever. The temperature, however, is 
atypical, as a general thing is not marked, and frequently is so 
slight that it entirely escapes notice. 

The purest type of the disease is observed in that form which is 
an acute general infection and which is observed so frequently in 
infants. There is usually 
a marked and rapid loss 
of flesh and strength and 
innumerable and varied 
objective symptoms are as- 
sociated, as one organ or 
another becomes more 
prominent in the infectious 
process. 

Generally, in spite of the 
most rigid regulation in the 
diet and its most careful 
preparation, the infant fails 
to thrive, and loss of appe- 
tite, vomiting, and diarrhea 
or constipation may lead to 
a suspicion of some diges- 
tive disorder. The child 
steadily loses despite every 
care. Cough is usually not 
a marked feature at this 
time. The general symp- 
toms are due in the main to a general intoxication, to local irri- 
tation, and to interference with function. 

The whole course of the disease exhibits a steady and rapid fail- 
ure of nutrition and of function, and as each day passes the child 
is less capable of performing those physiologic functions which are 
necessary to health and eventually to life. In many instances 
such cases are diagnosed as marasmus, and this is not surprising 
when the similarity is so great. 
28 




Fig. I21. — Showing the condition which is most 
common in the later stage of pulmonary tuberculo- 
sis. 



434 tuberculosis 

Every precaution should be shown to obtain a clear history of 
the little one's family, of its past and present surroundings, and 
of the possibility of infection. The history will usually (almost in- 
variably) show that the marasmic baby was perfectly nourished 
at the time of birth, and later on in its career there occurred a defi- 
nite cause for the present condition, and this cause was either im- 
proper feeding and care or occurred as a consequence of some gas- 
trointestinal disease. 

Upon the other hand, the tuberculous child is usually very poorly 
nourished at the time of birth, or it shows such a condition very 
shortly after birth without adequate cause being found for the 
same. In other instances the infant has some disease which ren- 
ders it more liable to infection (as in the catarrhs which are asso- 
ciated with rubeola, pertussis, etc.), and following that disease 
signs of inanition and wasting occur without sufficient cause. A 
careful examination fails to reveal any error of diet or feeding, and 
such a history should at once arouse a suspicion of tuberculosis. 

But the diagnosis cannot be positively made until later in the 
disease, when the local signs are discoverable, usually in the lungs. 
If the elevation of the temperature has been marked enough up to 
this time to give evidence of its hectic character, it becomes now 
more irregular, but is never high unless in the presence of some com- 
plication. The cough becomes a feature now, but is not wearing. 
Accelerated breathing occurs, and is out of all proportion to the low 
temperature. The local signs in the chest may be those of a bron- 
chopneumonia or of a localized bronchitis. The gastro-intestinal 
tract at this stage becomes the seat of many and marked disturb- 
ances, which are in nearly every instance traced to the generally 
devitalized condition of the child. 

The typhoidal type of the disease occurs in older children, and 
because of their greater vitality they resist the ravages longer than 
the infant. The tedious malaise, increasing loss of strength, intes- 
tinal disturbances, and the supervention of a typhoidal state may 
make the similarity to enteric fever somewhat marked. 

The fever is of a more continued type, and preceding its devel- 
opment there is usually an indefinite period of indefinite symptoms, 
which, looked upon separately, are of apparently little consequence, 
but which, taken collectively, are very suggestive. Such a child 



tuberculosis 435 

is usually delicate, and without apparent reason there are marked 
anemia, little or no gain in weight and strength, and an easily de- 
ranged digestive system, so that the symptoms are simply those of 
a general decline without adequate cause. 

After a few weeks of such symptoms fever appears, and while it 
is not high, it is continuous and without apparent cause. Then, 
in from one to three weeks, local signs develop. Associated with 
the fever there is one constant sign — wasting, which may not be 
rapid, but is invariably progressive. 

Cough is present and may prove wearing to the child, and the 
physical signs are those of a bronchopneumonia associated with 
the general symptoms of the typhoid state. Breathing is accele- 
rated, and the physical signs are generally situated at the apex of 
the lung. 

It is before the occurrence of definite local signs that the diagno- 
sis is so difficult, and the history is of great value in differentiation, 
the long prodromal period being markedly in favor of a diagnosis 
of tuberculosis. Then we must consider carefully the etiologic 
factors of each disease. 

It may happen that the latter are not clearly determined and the 
obtaining of the family history may be unsatisfactory, and in that 
situation some dependence might have to be placed upon the occur- 
rence of a recent tumor of the spleen. If the typhoid infection is 
severe enough to simulate tuberculosis, the splenic enlargement 
is marked, while in tuberculosis, if such an enlargement occurs at 
all, it is slight. 

It will be necessary to inquire carefully into the fact as to whether 
or not typhoid fever is epidemic. If the Widal reaction is act- 
ive, it is strong proof of typhoid fever. In favor of a diagnosis of 
tuberculosis are the atypical but not very high fever, severe cough, 
continuance of the symptoms unabated during the third week, and 
constipation. There may be cough in the first week of typhoid 
fever, due to an associated bronchitis, which is common, but the 
cough is never severe; the disease shows some amelioration dur- 
ing the third week, and diarrhea is rather common. 

When the tuberculous process becomes localized in the lungs, 
there is then a combination of symptoms which are dependent upon 
the general characteristics of the affection in addition to those 



43 6 TUBERCULOSIS 

dependent upon the particular type of lung involvement. A child 
who is suffering from a tuberculous infection of any part of the 
body, or who is affected with any exhausting condition, may 
readily develop a tubercular bronchopneumonia. 

Tuberculous pneumonia exhibits signs practically similar to those 
of simple bronchopneumonia when a physical examination of the 
chest is made, except in one particular, and that is of position of 
the signs. Either disease may affect any portion of the lung, but 
there is a distinct preference shown, in the large majority of cases, 
tuberculosis affecting the anterior portion of the lung, the mam- 
mary region, the axillary region, or the apex. If the location is 
posterior, then the apex is the part affected usually. On the other 
hand, simple bronchopneumonia affects, by preference, the lower 
lobes posteriorly. 

After the seventh year of life the physical signs of tuberculous 
pneumonia more closely approximate the adult type. The physi- 
cal signs naturally group themselves under four heads : localized 
bronchitis, partial consolidation, complete consolidation, and the 
formation of a cavity. 

Then there is a further natural division, based upon the clinical 
course of the disease : the rapid cases, in which the duration of the 
disease is from four to eight weeks, and the protracted, in which 
the affection lasts from two to eight months. But whether the case 
is rapid or protracted, there is little difference in the general symp- 
toms. 

The data upon which a diagnosis is based are of two kinds : that 
which relates to the patient and that which relates to the disease. 

The family history must be carefully gone over and especially 
in regard to the occurrence of either recent or remote cases of tu- 
berculosis. Then inquiry should be made in regard to the freedom 
of attendants from the disease, and also of the playmates. All 
the surroundings of the child must be examined by the physi- 
cian, so as to determine the possibility of a source of infection. 

There are many other facts that will help one to a correct diagno- 
sis: if acute symptoms develop during rubeola and persist, there 
may be a tuberculous process present or a simple bronchopneumo- 
nia; if the symptoms are less acute and delayed until the period 
of convalescence from rubeola, tuberculosis should at once be sus- 



TUBERCULOSIS 437 

pected. If in the convalescence from pertussis the symptoms are 
slowly developed, tuberculosis is indicated. 

If the family history is positively clear, no source of possible in- 
fection being detected or suspected, and the surroundings all good, 
a diagnosis of bronchopneumonia is made with good reason, no 
matter how protracted the affection and unusual its course, pro- 
vided always, among the features mentioned, that the child was 
previously healthy. 

If the pulmonary affection remains doubtful and meningitis 
develops, it almost invariably proves the tuberculous nature of the 
lung condition. Simple meningitis may follow bronchopneumonia, 
but the combination is so unusual that tuberculosis with secondary 
meningeal infection should at least be thought of and eliminated 
if possible. 

The development of bronchopneumonia is almost always rapid, 
while the course of tuberculosis is protracted, the onset preceded 
by premonitory symptoms, which may last for several days or 
weeks, fever is more constant, anemia is much more marked, and, 
what is of most importance in differentiation, wasting is more 
marked and progressive. Of course, if the presence of the tuber- 
culosis bacillus is determined, then the diagnosis is positive. 

Tuberculosis of the bronchial lymph-nodes is generally associated 
with tuberculous processes in other parts, but at times it exists as 
the most important and at times the only detectable lesion. The 
symptoms of tuberculosis of other parts may be insignificant or 
entirely lacking. But as swelling of the bronchial glands may 
occur in other diseases (notably in syphilis), even though infre- 
quently, care must be exercised to corroborate the suspicion of a 
tuberculous cause by other evidences. 

The younger the child, the easier does the involvement of the 
glands become, and when symptoms appear, they are those which 
are due to pressure principally. If pressure affects the recurrent 
laryngeal or the pneumogastric nerves, there is more or less hoarse- 
ness, dry, persistent, spasmodic cough, and perhaps some facial 
edema. If the trachea or a bronchus is involved, then dyspnea 
occurs, usually in paroxysms, and is generally associated with 
facial edema. During the paroxysm the child may throw the head 
forcibly backward in a tonic spasm, and give evidence of much 



438 TUBERCULOSIS 

suffering. Pressure over the great vessels adds cyanosis to the 
picture. 

More importance must be placed upon the occurrence of these 
latter symptoms (cough, dyspnea, cyanosis, facial edema) than upon 
the physical signs, which are unfortunately complicated by the 
large size of the glandular swelling. As not a few of these cases 
are first seen by the physician because of the laryngeal symptoms, 
and because in several instances the signs of tuberculosis are insig- 
nificant, care must be exercised to eliminate all other cause of lar- 
yngeal stenosis (see page 85). 

Tuberculosis of the brain is almost invariably a secondary con- 
dition, so that the diagnosis is usually made when its general symp- 
tomatology is understood, because one is naturally on the lookout 
for its occurrence. The symptoms depend largely upon the size 
and number of the tubercles, and if very large, then there are 
added the evidences which are observed upon the exterior of the 
skull (enlargement) or upon the eyeball (protrusion). 

The general symptoms are due to cerebral irritation, so that in 
a child who has been previously affected with a tuberculous proc- 
ess, we may observe more or less restlessness, stupor, or delirium, 
associated with attacks of vomiting or nausea, disorders of the 
cranial nerves, visual disturbances, motor or sensory paralysis, 
or incoordinations, etc. 

These at once lead to a suspicion of secondary infection, and by 
the application of the usual methods of cerebral localization, the 
lesions are usually more definitely located. As vomiting is an early 
symptom, if it occurs without apparent cause during the course 
of tuberculosis, it should arouse suspicion of meningeal involve- 
ment. Many times vomiting and some gastro-intestinal disturb- 
ance will persist in a mild form for several days as the first symp- 
tom, and unless one is upon his guard and notes the apparent 
lack of cause and mildness and persistence of the disorder, he will 
treat it as a digestive disorder, much to his chagrin later on. 

Within a week or two following such symptoms the child be- 
comes gradually worse, with marked cephalalgia and irregular tem- 
perature, but at the same time with a pulse which does not increase 
in ratio as the temperature is elevated. Then follows a period in 
which the child is either listless or irritable (these may alternate), 



tuberculosis 439 

with a tendency to somnolence which may be marked. The whole 
condition steadily grows worse, the respiration becomes irregular, 
and the skin so sensitive that redness may be caused by the slight- 
est pressure (the latter is not a constant feature, however). 

There finally occur rigidity of the musculature of the neck, re- 
traction of the abdomen, more elevation of the temperature, in- 
ability to take nourishment, paralyses, Cheyne-Stokes respiration, 
prostration, and probably terminal convulsions. The whole 
course may run but a few days or may be prolonged to several 
weeks, but in younger children the shorter course usually obtains 
(for a detailed description see page 403). 

An involvement of the peritoneum as a primary affection is rare, 
but it does occur. For the purposes of diagnosis it is only need- 
ful to recognize two forms of the affection — the plastic and that 
which is associated with ascites. 

Sometimes there is an indefinite period in which diarrhea or con- 
stipation, or the alternating of the two, may exist, and be asso- 
ciated with indefinite abdominal pain. Such a condition natu- 
rally leads to the suspicion of some gastro-intestinal disturbance, 
and usually it is not until considerable enlargement of the abdo- 
men has taken place that the correct diagnosis is made. When 
enlargement takes place, the abdomen assumes a more oval shape, 
on account of compression at the sides and the tension of the walls. 

This form of the disease is much commoner than is generally 
supposed, and is the chief cause of ascites in children who exhibit 
moderate elevations of temperature. Palpation of the abdomen 
shows that it is sensitive and swollen, and tender glands may be 
distinguished, as are also matted masses of the intestines and the 
peritoneum. If the case is one which does not go on to purulent 
degeneration, the course of the disease is prolonged indefinitely, 
with alternate periods of improvement and decline (for a detailed 
description see page 138). 

In all parts and organs of the body, except the lungs and intes- 
tines, a tuberculous process is usually secondary, so that the diag- 
nosis is thereby simplified, but it must be distinctly remembered 
that primary affections of other parts and organs do occur, al- 
though this is not the rule. We have up to this point considered 
the more acute forms of the disease, and before taking up a more 



44-0 TUBERCULOSIS 

chronic form which is most observed in older children, I wish to 
refer the reader to two other sections — that dealing with ' ' Tubercu- 
lous Meningitis" (page 403) and the one on "Tuberculous Disease 
of the Bony Structures" (page 460). 

Chronic pulmonary tuberculosis is very infrequent in young 
children, because their resisting powers are such that they suc- 
cumb to the disease before the process is far advanced. But 
with older children, who are better equipped to withstand the rav- 
ages of the disease, a chronic pulmonary tuberculosis is not uncom- 
mon. Usually it is observed after the seventh year of life. There 
is a pathologic difference as to whether the disease begins as a 
chronic condition or is developed from an acute attack, but 
clinically there is no distinction ; the result is about the same in 
both cases. 

While every portion of the lung may be affected, the resulting 
cavities from the breaking down of the caseous nodules have usu- 
ally a central location. The symptoms may not be markedly dis- 
tinctive when taken separately, but the usual picture is that of 
successive stages of bronchitis, bronchopneumonia, and abscess 
formation, and the usual course is one of periods of improvement 
followed by periods of retrogression. With the progress of the 
disease the anemia becomes much increased in degree, the child 
fails progressively in strength, night-sweats occur, and the slight- 
est cause is usually sufficient to bring about various serious disor- 
ders. The gastro-intestinal tract is particularly liable to disturb- 
ances from slight causes. 

The temperature is irregular, following somewhat the activity 
of the process, and the complications and the respiration and pulse 
show a similar tendency. The sputum is not usually abundant 
and does not become purulent until late in the disease, if at all. 
Physical signs are deceiving : deep-seated cavities are hard to dis- 
tinguish ; superficial ones may be suspected and yet the true con- 
dition present may be a superficial bronchus or bronchiole; the 
respiration at times is but little disturbed. 

I have purposely left the consideration of the diagnosis of most 
of the varied forms in which tuberculosis appears in children until 
this time, for there are many features which aid in the diagnosis 



TUBERCULOSIS 44 1 

which would have to be repeated and repeated unless taken up 
collectively. Some differentials have already been discussed. 

The diagnosis of tuberculosis in young children depends mostly 
upon the characteristic symptomatology, and the one who has 
this most clearly fixed in his mind will be the one most likely to 
make an early and correct diagnosis. 

An inquiry in detail into the family history of the patient, of 
his previous history and surroundings, and of the fact as to whether 
or not he has suffered from any disease which is liable to be fol- 
lowed by tuberculosis, is of absolute and of great importance in 
the diagnosis. And while speaking of the diseases which are often 
followed by tuberculosis, I may state that it most frequently fol- 
lows the catarrhs which accompany rubeola, pertussis, and in- 
fluenza ; it seems to be the catarrh rather than the disease itself 
that offers the favorable ground. 

Next in importance is the examination of the sputum, if it can 
be obtained; and if not, then there is usually sufficient material 
brought from the throat by the act of vomiting to allow of an ex- 
amination. Generally speaking, tuberculous processes attack the 
upper parts of the chest in preference to the lower portions, but 
this is not uniformly so. It is really only in the commencement 
of the disease that much doubt exists, and careful observation, 
corroborated by a carefully taken and complete history, usually 
soon clears up the difficulties. 



SCROFULOSIS 

Scrofulosis might well be defined as a general state of malnu- 
trition with a marked inclination to the occurrence of chronic in- 
flammation of different tissues and organs under the influence of 
the slightest irritation. There is one quite constant feature of the 
condition, and that is that the neighboring lymphatic glands are 
almost invariably involved, and remain enlarged for a very long 
time after the subsidence of the primary cause of the inflamma- 
tion. The age at which the symptoms first show themselves is 
usually between three years and ten years, and the situation, the 
cervical glands. Scrofulosis is essentially a disease of childhood, 
for after the time of puberty a subsidence of all symptoms is char- 
acteristic. 

The glandular swellings are the first signs of the disease, and 
this may occur very gradually. If there is a hyperplasia, then 
each gland may be palpated singly, but when caseous degenera- 
tion takes place, the glands are larger and coalesce, so that the 
contour of the part is partly destroyed. Very frequently the en- 
largement is not progressive, but shows distinct periods in which 
improvement or arrest takes place. The skin may show signs of 
an obstinate eczema or impetigo, and the eyes be affected with 
conjunctivitis, keratitis, etc. 

When the cases are of the rapidly developing type, the glands 
which are affected attain a considerable size within one to three 
months, and at first are movable and clearly defined. As degener- 
ation occurs, this distinctive outline is lost and they become ad- 
herent, first to the deep structures of the part and then to one 
another. When softening takes place, there is distinct fluctuation 
and the skin over the glands becomes discolored. Rupture results 
in the outpouring of thick pus. 

In the slowly developed cases the glands are usually adherent to 
each other, but not to the deep structures. They are covered with 
normal skin, for suppuration is not the rule. 

It will not be necessary to mention all the conditions which 

442 



SCROFULOSIS 443 

arise as the result of scrofulosis : the statement made at the first 
part of this section is sufficient to show that almost innumerable 
conditions may be present, for scrofulosis is a malnutrition with 
tendency toward all kinds of inflammation. 

The diagnosis is not always easy, for not all cases show a decided 
involvement of the glands, and many other conditions do. In 
false and in true leukemia the glandular swelling which occurs 
is much more general and pronounced, besides being more painful. 
In true leukemia there is a marked chronicity, with marked pallor 
of the skin, enlarged spleen, and an increase in the white corpus- 
cles. 

In late hereditary syphilis (that is, in cases in which the symp- 
toms have been so slight during the first year as to be overlooked) 
the symptoms are very similar, but their character differs, as does 
the history also. However, one must be guarded in taking a syphi- 
litic history, denials are so frequent, and the parents might be all 
right at the time, but affected at the birth of the child. 

There may be considerable inflammatory rhinitis in scrofulosis, 
but in syphilis there is a chronic ulcerative rhinitis with destruc- 
tion of the septum. Periostitis of the bones of the leg is com- 
mon to syphilis, but synovitis of the small bone joints is the rule 
in scrofulosis. 

Gummata and ulcers with clean-cut edges are evidence of syphi- 
lis, while in scrofulosis there may be at times nodes in the subcuta- 
neous cellular tissue, the favorite situations being the buttocks, 
thigh, and cheek. Then of immense value in the differentiation 
is the result which is obtained by appropriate treatment. 

Scrofulosis is often confounded with tuberculosis, but that they 
are not identical is shown by the good effect of treatment upon 
scrofulous children, by the occurrence very commonly of cases in 
which the other members of the family are perfectly healthy, by 
the absence of the tuberculosis bacillus, and the tendency to com- 
plete recovery at the time of puberty. That scrofulosis offers a 
very favorable ground for the development of tuberculosis is 
granted, and, in fact, the inflammatory products of scrofulosis 
are unstable, and, accumulating in some organs, may in time bring 
about an actual tuberculization. 



RACHITIS 



This disease is essentially dietetic, with hygienic conditions be- 
ing an important factor, and it 
belongs to the first three years of 
life. The disease does not spare 
the nursing child, if that act be 
unduly indulged in, and so we 
encounter it in nurslings after the 
first year or a little more, when 
all other nourishment but the 
breast milk has been denied the 
infant. The usual time for the 
manifestation of the first symptoms 
is between the sixth and the fif- 
teenth months, although there are 
congenital and late cases. 

There are many things which 
may lead one who is experienced 
in observing a large number of 
children to make an early diag- 
nosis, or to predict the occurrence 
of the disease, unless conditions 
are changed. Thus, we know that 
if a chronic state of dyspepsia 
occurs early in life, no matter what 
the manner of feeding the infant 
may be, rachitis is almost sure to 
be evidenced later on. If an in- 
fant is fed upon some one of the 
proprietary foods or upon condensed 
milk, and nothing else is added to 
the dietary, we are safe in predict- 
ing the occurrence of the disease, 
especially as the child sleeps, may be 




Fig. 122. — Rachitis. This figure is 
illustrative of a child of fifteen months, 
who is a victim of rachitis. The parents 
noticed nothing wrong with the infant, 
except that he walked "bow-legged," 
and it remained -for the medical atten- 
dant, who was called in to see another 
child, to make the diagnosis and point 
out to the parents other evidences of 
the condition. The deformities, which 
were becoming quite evident in this 
case, are well illustrated in figures 123 
and 124. Note the pendulous abdomen 
in this figure. 

Sweating of the head, and 



444 



RACHITIS 



445 



the first indication that there is something wrong with the child. 
Baldness of the occiput has the same value as a diagnostic sign. 
Unfortunately, these cases are usually not seen early, and then 
one has to depend upon the previous history of the child. AVhen 
this is obtained, we usually find that for months previously the 
infant has been restless at night, has been constipated, sweats 
about the head (and therefore is easily subject to attacks of rhi- 
nitis), or is bald at the occiput and is anemic. 

I have found in most of my cases anemia and a flabbiness of the 




Fig. 123.— Rachitic deformity. 



Fig. 124. — Rachitic deformity. 



musculature as the earliest symptoms. The first appreciable bony 
change is that which occurs in the ribs. It is known as beading of 
the ribs and as the rachitic rosary, and consists of the formation of 
nodules at the junction of the costal cartilages and the ribs. Some- 
times it is very slight, and remains so even when the case is severe. 
but in other instances it is very prominent. Most of the slightly 
developed rosaries are explained at autopsy, when it is found that 
the nodules are upon the internal surface mostly. 



446 RACHITIS 

If the infant be under six months, eraniotabes may be present. 
These are soft spots in the cranium, which are generally situated 

^ over the occipital or posterior portions of 

the parietal bones, are from one-quarter to 

three-quarters of an inch in diameter, and 

upon pressure give to the examining hand 

a sensation like the crackling of parchment 

under the fingers. After six months cranio- 

tabes are very infrequent. The head soon 

m Mk appears to be out of proportion to the size 

f%L £ 0I * t ^ Le body, anc ^ an actual enlargement 

H mt may take place as the result of thickening 

of the frontal and parietal protuberances. 

The result is that the head assumes a some- 

P M W what square shape, being flattened at the 

occiput and vertex. The closure of the 

fontanelle is delayed in rachitis, but hydro- 
Fig. 125.— Rachitic deform- , 1 r . i 1 -1 1 

it cephalus must first be excluded as a cause. 

Softening of the ribs is soon evidenced by 

the loss of the normal shape of the chest ; the normal curvature 

of the ribs is lost and they become straighter. The chest then 
appears to be more or less compressed later- 
ally, and the sternum is forced forward. 

There is an almost constant fermentation 
going on in the intestine, and the abdomen 
becomes quite distended. This abdominal 
distention finally extends until all portions 
of the abdomen are involved and the lower 
portion of the chest below the point of in- 
sertion of the diaphragm is affected. The 
result of such distention is that a groove is 
formed which divides the upper and narrow 
part of the chest from the lower and dis- 
tended part, forming the rachitic girdle. Fig . I26 ._ Genu val . 

The characteristic bonv changes in the &"*• ^ e ^ ale . c f d five 

years old (Napier). 

long bones of the body are thickening at the 

lower ends of the forearms, so that the wrists seem to be en- 
larged. The general softening of the bones naturally results in, 




RACHITIS 



447 



more or less deformity and the legs are the subjects of various 
curves. 

The rachitic child is notably weak in the muscles, and this is so 
marked at times that the little one will not attempt to walk and at 
times cannot even assume an erect position. Following the law 
of gravitation, the body is bent so that the spinal column is arched 
with the convexity backward. The curvature of the spine 
which occurs in rachitis is general, in contradistinction to the local- 
ized curvature of Pott's disease. Rotary curvature is much less 
common. The ligaments, and especially those about the large 
joints, are very lax and lead to 
more or less deformity. Muscular 
power may be so weakened and the 
ligaments so lax as to suggest the 
presence of paralysis. 

The rachitic infant is notably the 
subject of an easily deranged diges- 
tive system. The gastro-intestinal 
tract fails to perform its functions 
properly, so that there is an inclina- 
tion to diarrhea or constipation, and 
always to chronic meteorism. The 
respiratory organs also show a 
marked inclination to chronic or 
oft-repeated catarrhs, so that the 
child is constantly in danger from 
the occurrence of serious disease. 

The nervous symptoms are many 
and varied. Restlessness at night, as has been stated, is one of 
the earliest. Attacks of laryngismus stridulus, tetany, or general 
convulsions are not uncommon, and of the first two of these it 
may be said that they occur most frequently in rachitic children. 
The susceptibility to the occurrence of general convulsions is very 
marked in the child affected with rachitis, so that the slightest 
causes will bring on an attack. 

In each case, of course, all the associated symptoms will differ : 
in one infant it may be the mucous surfaces which suffer most, in 
others the respiratory apparatus, the nervous system, or the diges- 




Fig. 



127. — Deformity from rachitis 
(Napier). 



448 



RACHITIS 



tive system, and the manifestations of the disease depend some- 
what upon the age of the infant and its surroundings. The dura- 
tion is months, for the disease is essentially chronic. Active symp- 
toms usually continue for from two to fifteen months, but may 
persist for a longer period. 

It is only during the early stages of development that the diag- 
nosis is at all difficult, and even then, after taking a history of the 
previous condition of the infant, and particularly in regard to its 
nourishment and surroundings, there is practically no chance for 
error in the diagnosis of the disease. 

All the early symptoms (anemia, restlessness at night, head- 





Fig. 128.— Flat foot. 



Fig. 129. — Talipes calcan- 
eus. 



Fig. 130.— Talipes equinus. 



sweating, baldness of the occiput, craniotabes, enlarged fontanelle, 
delayed or difficult dentition), taken singly, may mean some- 
thing entirely different than rachitis, but, taken together, or when 
most of them are present at one time, they can mean nothing else 
but this disease. 

It is the undue prominence of separate symptoms which occa- 
sionally causes the trouble. There may be a slight involvement 
of the bony structures, but a most pronounced anemia associated 
with a large and solid spleen, so that the question as to a compli- 
cation, leukemia, being present is at once suggested. Microscopic 
examination of the blood will at once determine this point. The 
enlargement of the head may be such as to suggest hydrocepha- 



RACHITIS 



449 



lus, but in either disease there are other symptoms peculiar to each 
which are soon evident upon examination. 

The musculature may be prominently affected (particularly 
of the legs) and the bony changes slight, and such cases offer much 
similarity to actual paralysis. A study of the electric reactions 
will at once determine the question in regard to infantile spinal 
paralysis (page 361), and the presence of more or less marked cere- 
bral symptoms, exaggerated knee-jerk, and spastic paralysis of 
the legs will be sufficient to distinguish a cerebral birth-palsy. 





Fig. 131. — Talipes valgus. 



Fig. 132. — Talipes varus. 



The possibility of mistaking syphilis is rather remote, for in the 
beginning the lesions of syphilis are more like soft infiltrations over 
the bones, and the part affected is not the end, but the junction of 
the shaft and the epiphysis, or in later changes the shaft of the bone 
is affected. The history of the two diseases is markedly different. 
Bone changes are early in rachitis, but in syphilis they occur, as a 
rule, late in the second year, and the skull is not affected. 



HEREDITARY SYPHILIS 

Hereditary syphilis must not be confounded with the acquired 
form, which in its course and various phenomena does not differ in 
any marked particular from the acquired form of adult life. An 
inability accurately to make a distinction between the two forms 
may result disastrously to the reputation of a faultless person. 

Snuffles, pemphigus, and pseudoparalysis are never found in the 
early acquired form in children, while the occurrence of a chancre, 
no matter what its situation, settles all uncertainty as regards 
the disease being acquired. In addition to this, the presence of 
Hutchinson's teeth and the peculiar claw-like appearance of the 
nails are strong evidence in favor of the acquired form. 

A child may readily become inoculated with the disease by kiss- 
ing a person with such syphilitic manifestations as mucous patches, 
fissures, and ulcers, or acquire it from a nurse who is syphilitic. 
The possibility of vaccination as the mode of inoculation has to 
be thought of, for in a few sections the humanized virus is still used. 
Criminal assault is not an unusual means of infection, and it is in 
just such cases that the utmost skill and precaution must be exer- 
cised to distinguish between the hereditary and the acquired forms. 

No matter how young the child may be, a somewhat typical 
course of the phenomena of syphilis, following the appearance of a 
chancre, or primary adenopathy, is the only substantial proof 
which we have that the case is one of acquired syphilis. 

Not alone in making a distinction between the two forms, but as 
a matter of direct diagnosis of the disease, the family history is a 
very important matter. It is usually very difficult to obtain a 
perfectly satisfactory history, for parents will either wilfully de- 
ceive or make misstatements through ignorance. In taking a 
history there are several points which it is well to consider : 

(a) The tendency of the children of a family to suffer from un- 
accountable anemia and malnutrition during early life is very sug- 
gestive. Several children of the family may be so affected, de- 
spite the fact that the hygienic surroundings and the dietetic care 

450 



HEREDITARY SYPHILIS 45 1 

are both excellent. Briefly stated, the situation is simply this: 
if two or more children in a given family are affected with anom- 
alous or unusual types of disease, and the cause of such is not well 
defined, a strong suspicion of hereditary syphilis should be enter- 
tained. 

(b) Delayed development without apparent cause, or occur- 
ring from very slight causes in two or more children of a given fam- 
ily, should arouse a similar suspicion as to the cause. 

(c) The occurrence of a rachitic type of skull, without the other 
signs of rachitis being more or less marked, is suggestive of heredi- 
tary syphilis. 

(d) A history of the abortive habit in the mother will at once 
suggest the possibility of an underlying syphilitic taint. 

Late hereditary syphilis occurs as a relapse of an old syphilis, 
the early symptoms having been attributed during early life to 
some other cause, or having been so mild at that time that they 
were neglected. With our present knowledge of the disease I 
believe that we are justified in accepting this as the explanation 
of the occurrence of these apparently late symptoms. They 
are usually those of the tertiary period, and are most frequently ob- 
served during the time between the fifth and tenth years, but may 
appear early or late in rare cases. 

The symptoms are numerous enough, as a rule, but are far from 
being characteristic, so that the family history becomes a very im- 
portant factor in the diagnosis. Such a history may be very in- 
definite, and much patience must be exercised to bring it out. To 
be of service, it must establish the fact that syphilis has occurred 
in the family. 

Methods of Acquisition. — Can the father alone infect the child ? 
This question has not been satisfactorily answered up to the pres- 
ent time. The great uncertainty is, whether the child can be 
affected at all without the father first infecting the mother. No 
doubt the father may hand down to his offspring certain conditions 
which, while they are not purely syphilitic, yet are derivatives of 
that disease, and the result upon the infant is that it presents un- 
usual perversions of development, of nutrition, and of mentality 
which are accounted for in no reasonable way. This fact is im- 
pressed very strongly by the birth of a much weakened type of off- 



452 HEREDITARY SYPHIUS 

spring, which are the product of apparently healthy mothers who 
have husbands who are syphilitic. The result of specific treat- 
ment in these cases is their rapid improvement. 

Does the mother infect the child? It cannot be too strongly 
stated that if the mother at the time of conception is syphilitic, 
the offspring will surely be. In the mean time the father may re- 
main healthy, as the power of the woman to infect the child per- 
sists for a longer time than her power to infect the man. 

If both parents are healthy at the time of conception, and the 
woman becomes infected later, will she transmit the disease to the 
child? This is a much mooted question, but there seems to be 
abundant evidence to prove that up to the seventh month of preg- 
nancy, if the mother becomes infected, the child inherits the disease. 

It is rather rare that a woman in full syphilis and pregnant does 
not abort. Active treatment has apparently no effect in checking 
this tendency. The cause of such an abortion is usually the death 
of the fetus. It may be blighted early in the pregnancy or there 
may be later shrinking with subsequent death. Generally there 
are serious visceral changes and abnormalities which occur to de- 
stroy life. Changes in the placenta are very common, affecting 
the life of the fetus and giving rise to profuse hemorrhages from 
partial detachment. 

The syphilitic child at birth may be rather shrivelled looking, on 
account of the lack of fatty tissue in its body. The face generally 
has a characteristic pinched look, and very shortly after birth the 
expression is like that of an old man, and this becomes more and 
more noticeable as the infant ages. The infant may be covered 
with bullae from which the epidermis slips, leaving areas which 
are denuded, or blebs may be found upon the palms and soles only. 

Usually the birth is premature, with all the consequent train 
of symptoms. The usual dusky color of these infants is due to the 
general vascular tone being defective. The lesions maybe present 
at the time of birth, but this is very unusual, for they rarely de- 
velop until the third week or later. Excoriations of the quasi- 
mucous surfaces about the anus, the mouth, and the genitals are 
very common, and especially so of the anus. 

Snuffles develops almost invariably and is an early occurrence, 
in many cases being the only symptom for a long time which attracts 



HEREDITARY SYPHILIS 453 

attention to the existence of syphilis. Occasionally it occurs with- 
out any nasal discharge, but usually this is more or less abundant 
(of mucus) and may at times be tinged with blood. In rarer cases 
there is an epistaxis which is frequent and associated with no 
other discharge from the nose. There is one marked characteristic 
of the nasal discharge — if it once occurs, it is persistent. 

The occlusion of the nose may be so great as to interfere seriously 
with respiration and also the act of nursing. Frequently the dis- 
charge from the nostrils is very irritating; this, however, should 
not lead one into the error of assuming that the sores about the 
mouth are due to the nasal discharge (this has often been done 
and the diagnosis not made until some time later). The skin is 
thick and swollen at times. 

Not infrequently there appears a livid eruption which is macular 
and with well-defined borders, and affecting the skin especially 
about the genitals and face. The maculae are bright red in the 
beginning, but become more of a brownish color in time, and are 
followed by some desquamation, which is most marked upon the 
soles and palms. 

At other times there is a peculiar eruption which is almost iden- 
tical in character with pemphigus, consisting of bullae or blebs. 
These are filled with fluid which is slightly turbid and bloody, or 
the contents may be pus. When rupture takes place, the contents 
dry into a greenish crust and ulceration goes on underneath. The 
blebs are not numerous — in fact, there may not be more than three 
or four at most, but they are strongly diagnostic of syphilis. The 
usual situation is upon the soles and palms. The nails are dry and 
brittle and pustular onychias in the matrix are common. 

The bridge of the nose is broader than usual and lower also ; if 
much necrosis has occurred, it may be much sunken. The forehead 
is generally large and protuberant, and there is frequently a well- 
defined depression just above the eyebrows. The hair is not so 
apt to be involved, except that it is brittle and scanty and there 
may be patches of alopecia. 

The teeth are erupted late and show early decay. The changes 
in the teeth are many; all the teeth or only the middle incisors 
may be abnormally small, and slits remain between the teeth. In 
other cases they are covered with a false enamel which rapidly 



454 HEREDITARY SYPHILIS 

crumbles, allowing the teeth to rot and decay. On the surfaces 
of the teeth there are frequently calycif orm and transverse striated 
erosions which are sometimes single, forming a groove. Such 
changes in the teeth occur most often in hereditary syphilis, but 
are not limited to that disease alone, so that they must not be con- 
sidered anything more than suspicious. Particularly character- 
istic of syphilis is the presence of Hutchinson's teeth; these are 
characterized by the semilunar notching on the free edge of the 
two upper middle incisors. Besides this, the teeth are short, nar- 
row, and have rounded corners. 

The bones, the cartilages, and the articulations show character- 
istic changes in both early and late hereditary syphilis. The most 
frequently affected portion of the skeletal structure is the diaphyso- 
epiphyseal junctions of the long bones, and especially the tibia. 
In syphilitic osteitis in infancy the bones are more or less uni- 
formly enlarged, but. suppuration or necrosis is very infrequent. 

Of the long bones, the tibia is the most often affected, or there 
may be a simultaneous affection of several of the bones. The ap- 
pearance of the tibia is saber-like, for the bone has the look of be- 
ing compressed at the sides and has an apparent arch forward. 
This arch is, however, only apparent, for there is no actual curve, 
the appearance being due entirely to new-formed osseous tissue on 
the anterior surface of the bone. If this point is not well under- 
stood, there is danger of mistaking the deformity for a rachitic 
curvature; but in rachitis there is a definite curvature and not 
simply a unilateral thickening, and this occurs when the child be- 
gins to stand or walk. 

The new bone deposit of syphilis is the result of a specific peri- 
ostitis, and this is very painful in its beginning, the pain being 
prominent long before any other symptoms appear and being 
much worse at night. When the thickening appears, the pain dis- 
appears. Such a course (from the earliest appearance of pain to 
the formation of thickening) may occupy a period of four months 
or four years. In a few instances the pain is only elicited upon 
handling the child. 

Gummata are very common, appearing with greatest frequency 
on the anterior aspect of the bones of the leg and the skull. They 
are half spherical, limited swellings and are quite painful. In the 



HEREDITARY SYPHILIS 455 

beginning they are solid, but later there is distinct fluctuation, 
and about the same time they become more or less adherent to the 
skin. They are of varied sizes, from that of a pea to that of a small 
apple. Ulceration may take place. 

The various bone lesions are readily mistaken for scrofulosis. 
In the latter, however, it is the short bones that are most often 
affected and the epiphyses of the long ones. Caries is very apt to 
occur as the result of tuberculous infection. The pain during the 
whole course of scrofulosis is exceedingly slight, or more often ab- 
sent altogether, and the bone itself is not enlarged (the swelling 
is due to edema and infiltration of the soft parts) and there is a 
doughy feel to the tumor. 

On the other hand, during the course of hereditary syphilis, the 
long bones are the ones affected, and the enlargement is of the bone 
itself; pain is usually marked in the beginning and the tumor is 
solid and unilateral (that is, it occupies but one side of the bone). 

Interstitial keratitis is quite pathognomonic of hereditary syphi- 
lis, and when associated with the appearance of syphilitic teeth, 
it places the diagnosis beyond all doubt. The origin of such a 
keratitis is usually ascribed to malnutrition, but it is present in 
hereditary syphilis more often than in all other conditions put to- 
gether. It is evidenced by a diffused opacity of one or both corneas 
and develops slowly and without any signs of irritation. The 
duration is from six to twenty months, and the final result may be 
a few scarcely visible spots which remain, or there may be a per- 
fect clearing. When such a keratitis, Hutchinson's teeth, and 
deafness are associated together, they constitute what is called 
' 'Hutchinson's triad. ' ' Deafness is particularly indicative of syph- 
ilis if it occur without pain or a discharge of pus. 

The visceral lesions are by far the most important. This can 
be readily understood, for the processes of nutrition and growth 
in infancy are most active, and this of itself favors constructive 
change. The result is that the proliferation of new connective 
tissue about the parenchyma of any viscus is favored. Such in- 
terstitial proliferations are usually wide-spread, and any or all of 
the viscera may be involved in the process, but particularly liable 
to such conditions are the liver, the spleen, and the kidneys. 

Hemorrhagic effusions in all situations are common in the young 



45^ HEREDITARY SYPHILIS 

infant, and especially of the meninges, so that it is not uncommon 
to find cephalhematoma occurring in these cases. Under the in- 
fluence of prolonged or difficult labor, intracranial or subpericra- 
nial effusions are common. 

In its influence upon the nervous system the disease may act in 
various ways : 

(a) It may so affect the nervous system of the fetus as to mark- 
edly interfere with normal development. This is generally evi- 
denced by an arrest of brain development, which is responsible for 
many of the instances of idiocy which occur. 

(b) Lesions which are identical with those of the acquired form 
may be present in the new-born or occur shortly after birth. Then, 
again, they may not appear until later in life, but after the seventh 
year lesions of the nervous system become rarer. 

Evidences of an anomalous or unusual involvement of the ner- 
vous system by disease should stimulate a search for evidences of 
syphilis in the child. The reason why in one case we obtain many 
evidences of involvement of the nervous system, and in another 
case very few, is probably explained by the differing neurotic his- 
tories of the children and the influence of traumatism, which seems 
often to determine the development of certain neuroses. 



THE BONES AND JOINTS 

As landmarks the bones and joints of young children are not of as 
much value as in adult life. Usually they are well covered with 
tissue and cannot be so easily made out. It is quite necessary, how- 
ever, that one familiarize himself with the normal conditions, for 
the bones may be the seat of nutritive changes which will influence 
the skeleton, and therefore the body. 

The position of the bones in some instances may be influenced by 
the occurrence of paralysis. Nodules or nodes may be present, and 
are usually due to traumatism, to infection, or to syphilis. In the 
latter disease the favorite situation of such is upon the cranial 
bones or the shafts of the long bones, and they are generally 
bilateral or multiple. They are accompanied by tenderness and 
usually by marked pain, but are not so hard as exostoses. 

Then the joints, both large and small, may offer many deviations 
from the normal conditions. A swollen joint may suggest many 
conditions — may be due to injury, as in fracture, or to hereditary 
syphilis or rheumatism. If we observe in a child that the wrists 
and ankles are symmetrically enlarged, it is strongly indicative of 
rachitis. If there is an increasing swelling, with tenderness which 
is at times extreme, resulting in the child crying every time that 
any attempt is made to move it, it is indicative of scurvy. 

Swollen joints may also be due to acute arthritis of infants. 
It is important to note whether the affection be limited to one 
joint or affects several. When a single joint is affected, the 
process may be a local one and due to traumatism. But when 
several joints are involved, then we at once suspect a general in- 
fection, with some disease, such as rheumatism or tuberculosis. 

An affection of one large joint indicates an injury, rheumatism, 
or pyemia. An affection of several small joints points to scrofu- 
losis, tuberculosis, or rheumatism, while the affection of several 
large joints suggests a rheumatic infection. 

Then there are joint symptoms which are the expression oi sonic 
more or less severe general infection, as cerebrospinal meningitis, 

457 



458 THE BONKS AND JOINTS 

scarlet fever, purpura, scurvy, hemophilia, etc. All these are 
considered under their appropriate and respective headings. 

Acute Arthritis of Infants. — This disease has a sudden onset, 
with such well-marked local symptoms that the diagnosis is usually 
not difficult. There is at once evidence of pain, and soon there 
occurs a rapidly developing swelling about the affected joint. This 
swelling is at first diffuse, for the lesion is deep-seated. Tenderness 
is generally extreme, and redness, edema, and fluctuation soon 
supervene. At the same time there have been marked constitu- 
tional symptoms, for the disease usually occurs with a chill or con- 
vulsion, followed by high fever with wide variations, and accom- 
panied with marked and early prostration. The duration of the 
disease is from six to fourteen days, with the evidences of pus 
formation about the fifth day. 

The greatest error is in mistaking this disease for rheumatism, a 
disease which is so rarely manifested in this way in infancy that the 
error is hardly ever justified. There is certainly much more excuse 
for mistaking it for syphilitic epiphysitis, although there is a lack 
of the rapid course which is observed in acute arthritis. When 
the local signs of the disease are not considered too much apart 
from the associated constitutional ones, there is but little op- 
portunity for mistake. 

Infective Ostitis. — Inflammatory diseases of the bones are fre- 
quently associated with the exanthemata, and such an inflam- 
mation is an osteomyelitis, but usually with the brunt of the 
disease falling upon the deep layers of the periosteum. We do 
not yet know exactly why the changes which take place in the bone 
are so marked, or just how they are produced. But this we do 
know, that during the course of the acute infectious exanthemata 
there is a marked tendency to the occurrence of bone inflammation 
from slightly active causes. 

Acute Osteomyelitis. — A slight injury or the mere application of 
some irritant to a limb may be sufficient, under favoring circum- 
stances, to cause a vascular disturbance which fits the part as a 
nidus for the organism which starts the disease. 

The initial symptoms are, for the most part, those of a more or 
less severe attack of septicemia, but in very young children the 
symptoms are somewhat indefinite and misleading. The infant 



OSTEOMYELITIS 459 

or child may be fretful and cross, may refuse any food, and may 
scream vigorously when moved. But if osteomyelitis is present, 
it will always be noted that one limb is held motionless, and when 
an examination is made, it is found that tenderness is acute, the 
marked tenderness being near one of the epiphyses. Untreated, 
the joint is soon swollen and inflamed, and an abscess soon bursts 
into it. Or if the disease run a more favorable course, there is 
enlargement without abscess formation. 

The typical course of the disease is observed most often in 
children who are over two years of age, and it is not uncommonly 
observed between the ages of eight and fourteen. Generally it is 
a poorly nourished or debilitated child who suffers, and the onset 
is sudden, with convulsions or chill, vomiting, diarrhea, and 
severe headache. Sometimes the child is so ill that no complaint 
is made of pain at first, and the symptoms are then misleading. 
The temperature usually rises rapidly to 105 or 106 F., with 
morning remissions to 10 1° or 102 F., but accompanied in most 
instances with marked delirium. Altogether, it is a picture of 
acute septic poisoning that confronts us : there are profuse sweat- 
ing, dry tongue, enlarged spleen, etc. 

During the first forty-eight hours the only means of detecting the 
lesion in the bone is through the experienced touch, and it is usually 
only after the time for cure has passed that the disease is well 
made out. It will at once be seen that an early diagnosis is 
desirable, for it is in the early stages alone that much can be done 
by treatment. 

And, upon the other hand, there is hardly a disease in which more 
errors are made in the early diagnosis. First we are apt to think of 
the more common acute diseases, so that frequently the symptoms 
are ascribed to rheumatism. In considering the possibility of the 
latter, there are two things to take into account — the family history 
and the preceding condition of the child (see " Rheumatism "). 

The dangers of thinking that the symptoms are due to cellulitis, 
to tuberculous peritonitis, to tuberculous meningitis, and to scurvy 
are all very real, and it is only by a careful examination of the joints 
that these can be eliminated. 

Fractures. — While the symptoms of fractures in children are the 
same as in adults, many mistakes are made because they are not so 



460 THE BONKS AND JOINTS 

marked. They differ principally in two particulars: First, the 
pain in children is inconsiderable when compared with adults and 
crepitation is never as well marked. The deformity is apt to be 
very much less also, because the fracture is not so oblique and 
the musculature is weaker than in adult life. Then, again, ' 'green- 
stick" fractures are very common to childhood, and inattention 
to these apparently small details will lead to the most serious errors 
and the most embarrassing positions. 

The healing of fractures in childhood is rapid, the sequels are 
very few, and the results are good. 

Osteopsathyrosis. — Of this unusual condition, in which there 
is a tendency to repeated fractures, we know but little. The 
symptoms are those of ordinary fracture, but as slight violence is 
required to produce the result, there are less bruising, less swelling, 
and but little pain. It must be differentiated from the spontaneous 
fractures (epiphyseal separations) which occur in scurvy at times. 
Hereditary influence is strong. 

The diseases of the bones and the joints which are dependent 
upon the two diseases, tuberculosis and syphilis, are of such im- 
port that I have considered them in separate sections, and these 
follow (see Tuberculous Diseases of the Bones, page 460, and Syph- 
ilitic Diseases of the Bones, page 474). 



TUBERCULOUS DISEASES OF THE BONES 

As far as the tuberculous diseases which affect the bones and. 
the joints are concerned, the very first symptoms are the all- 
important ones, and the early recognition is necessary to prevent 
deformity, for when the disease is early defined, much can be 
done by surgical and mechanical intervention. 

The children who are affected almost always have a well-defined 
tuberculous history, and in many instances a well-defined tuber- 
culous lesion which has preceded. In many of the cases that seem, 
to be of primary origin little care has been taken to elicit the his- 
tory, and frequently at autopsy antecedent lesions are found which 
were overlooked during life. 

Just as an injury seems to determine the onset of tuberculous 
meningitis, so traumatism frequently acts as an exciting cause of 



TUBERCULOUS DISEASES OF THE BONES 



461 



tuberculous bone disease and determines its situation. The age 
at which tuberculous bone disease is most apt to occur is between 
the ages of three and 
seven years. 

There is generally, 
at first, a primary os- 
titis, and this shows a 
special preference for 
the articular portions 
of the long bones. 
The bones of the spine 
are the most fre- 
quently affected of all 
bones, and the disease 
may be located in 
any of the vertebras. 
Then, next in fre- 
quency, the hip is at- 
tacked, and, in the 
order named, the 
knee, ankle, elbow, 
wrist, and shoulder. 

The process which 
occurs in the bone is 
somewhat on a par 
with that which oc- 
curs in the tubercu- 
lous lung. The dura- 
tion of the bone dis- 
ease is from one to 

ten years, with three years as the average. Abscesses are formed 
in a large proportion of the cases and may burrow for considerable 
distances before reaching the surface. 

I shall take up the different diseases in the order of their fre- 
quency. 

Spinal Caries 

Pott's Disease. — The onset of Pott's disease is almost always 
very insidious, so that the disease may have existed for months 




Fig. 133. — A method much in vogue of eliciting pain 
in the spinal column when caries is suspected; by pressure 
forcibly applied to the head. This method is mentioned 
only to be condemned as unnecessary, useless, and as liable 
to cause further injury. 



462 



THE BONKS AND JOINTS 



without being detected. This happens because the symptoms 
are usually misinterpreted. The misleading feature is that pain, 
which is expected, is during the early stages of the disease referred 
to remote parts (for example, pain in the epigastrium is quite com- 
monly the very first sign which will lead to an examination of the 
spine by a careful observer, and yet, in most instances, the cause 
is sought for in the stomach). 

With an understanding of the process which is taking place in 
the bone, one would naturally expect to observe pain, but while it 

is an early symptom of the 
disease, it is at first referred 
to various portions of the 
body, following the distri- 
bution of the nerves which 
are affected by the process 
in the bone. The distribu- 
tion of pain is usually as 
follows, indicating the sit- 
uation of the lesion : 

Cervical disease: Pain 
is usually located above 
the site of the lesion, so 
that occipital neuralgia is 
common, or there may be 
pain at the sides of the 
neck. The pain may be 
excited only by motion or 
may be so constant as to result in a changed expression of the 
face. 

Dorsal disease: Pain is below the lesion and may be evidenced as 
an intercostal neuralgia, epigastric pain, or abdominal pain. 

Lumbar disease: Pain is referred to one of the limbs (lower) and 
may also be referred to the groin, thigh, buttock, or hypogastrium, 
but referred pain in lumbar disease is not as common as in other 
forms . 

Another constant feature of Pott's disease (besides the pain) is 
the occurrence of muscular spasm. Muscular spasm depends 




Fig. 134.— The stoop of a normal child. Much 
information may be gained by watching the child 
as he stoops ; if the spine is held rigidly or in an 
unnatural position, it will at once suggest an exam- 
ination of the vertebral column. 



TUBERCULOUS DISEASES OF THE BONES 463, 

largely upon the efforts of the child to limit or prevent motion at 
the site of the lesion. 

Cervical disease: The muscular spasm is commonly evidenced 
as a slight torticollis or opisthotonos, but the former is the more 
frequent. Later on, the whole musculature of the neck may be 
involved in the attempt to hold the head rigidly. 

Very early in the disease there may be a tendency for the child 
to support the head, and the positions assumed by the little one 
are all aimed at the prevention of motion, although it may be a 
long time before suspicion is aroused as to the cause for the 
peculiar positions taken. Generally these children are chastised 
because of their apparently lazy habits at school and at home. 

Dorsal disease: There is much care shown in walking, the spine 
being held stiffly, and when the recumbent position is assumed 
or the child arises, it is done with considerable deliberation. 

Lumbar disease: The gait is as characteristic as the attitude; 
the shoulders are carried well backward, the spine held stiffly, and 
locomotion is stiff with short steps. There is an awkwardness or 
stiffness in arising also. 

Lameness is early and usually coincident with the pain, and at 
the same time there may be some tilting of the pelvis, with slight 
lateral curvature of the spine. 

Now, when there is evidence of the existence of any of the above 
symptoms, the examination of the child exhibiting them should 
be most searching. Nothing short of stripping the child will suf- 
fice ; we are suspicious of the existence of a deforming disease, and 
it behooves us to give the child every chance possible to avoid such 
deformity by our early diagnosis and treatment. 

The physical examination has three points in view : (a) The de- 
tection of deformity ; (b) to determine the mobility of the spine ; 
(c) to detect the existence of secondary abscess or paralysis. 

During the early stages of the disease there is onlv a slight and 
general curve to the spine, but as the disease advances, then the 
typical angular curvature occurs. 

Cervical disease exhibits a rather late development of deformity ; 
certainly much later than the other forms. The neck appears 
thickened, and this is so in such a general way that it appears as 
though the head had settled on the shoulders. In the upper and 



464 



THE BONES AND JOINTS 



the central regions there is frequently an anterior prominence, but 
to determine this an examination of the posterior pharyngeal wall 
must be made by the finger. In the lower portion of the cervical 
spine kyphosis is common. 

Dorsal disease usually shows an early but slight lordosis, which 
later on is displaced by kyphosis associated with compensatory 
lumbar lordosis. Dorsal disease gives the earliest deformities. 

Lumbar disease may be very slow of development in regard to de- 
formity, and it is not unusual to detect an abscess before deformity 
is marked at all. The compensatory lordosis which occurs with dor- 
sal disease must not be mistaken for disease in the lumbar region. 




Fig. 135.— Test for psoas spasm. As the limb is gradually elevated by the right hand, if 
spasm be present, it is felt by the examiner's left hand. 



These deformities may be mistaken for deformities which are 
the result of rachitis. The most characteristic rachitic deformity 
is posterior kyphosis, but it is general and not localized. Usually 
it extends from the upper part of the dorsal to the sacral region, 
and unless it is of long standing, it entirely disappears when strong 
extension is made upon the limbs or the child is suspended. How- 
ever, there may be rotary curvature instead, but the former is 
the most frequent by far. These rachitic curvatures are usually 
observed in children under the age of three, and there are other 
and abundant evidences of rachitis present. It may be generally 
stated that all spinal curvatures occurring in children under the 



TUBERCULOUS DISEASES OF THE BONES 465 

age of three years are rachitic in origin, or at least due to some 
malnutrition. 

Mobility of the spine may be tested by making the child go 
through various acts, as stooping to pick up things, getting up 
from the floor from a sitting and also from a recumbent position, 
and this may be further studied by attention to the attitude as- 
sumed and the gait. The various positions which are assumed in 
these attempts to do as told is summed up in this fact : that the 
child endeavors by every means to save the spine as much as pos- 




Fig. 136.— Showing the method of determining the flexioility of the spine. In this ease it is 

normal. 



sible. There may be, and are, varying differences in the attitudes 
and motions, which are dependent upon the different situations 
of the lesion, but the aim of the child is always the same — to limit 
motion of the spine. By comparison with similar acts performed 
by a perfectly healthy child, the differences are more marked. 

While it is not usually necessary to do so, still at times the na- 
ture of the spinal curve maybe proved bv having the child lie upon 
its stomach on some hard surface (as a table), and then, by grasp- 
ing the ankles firmly and raising the body gently, the back becomes 
30 



466 THE BONKS AND JOINTS 

concave. An angular curvature does not disappear under such 
examination, but rachitic curvatures almost invariably do. 

After the mobility of the spine has been thoroughly tested, the 
examination must determine the presence or absence of abscess 
formation. When there has been the slightest suspicion of cervi- 
cal disease, an examination of the posterior pharyngeal wall should 
be made by the finger, for frequently abscess and deformity will 
be revealed by this procedure which cannot be detected in any 
other way. 

Occasionally, the very first symptoms which are marked enough 




Fig. 137.— Illustrating rigidity of the spine. 

to compel the parent to seek advice for the child are those which 
are due to the formation of a retropharyngeal or a retroesophageal 
abscess. When suspicion points to an involvement of the lumbar 
region, deep palpation may reveal the presence of a psoas abscess, 
but even before the signs of such a tumor are sufficient to be made 
out by palpation, passive motion of the thigh is accompanied by 
marked resistance to extreme extension. 

Before leaving the discussion of this part of the examination, 
it may be well to mention some errors that are commonly made, 
so that, being warned of such, one may be more guarded in the 
examination. Psoas abscess may be found deep in the iliac fossa 



TUBERCULOUS DISEASES OF THE BONES 



467 



or at the upper, inner aspect of the thigh, and has been mistaken 
for one of the following conditions : perinephritic abscess and her- 
nia. Because of the stiffness of the muscles, the pain, and perhaps 
the lack of a clear history, the cases are often treated as rheuma- 
tism. Lameness at the hip is very frequently the result of a psoas 
abscess, but is commonly attributed to disease of the hip-joint, 
but in the latter resistance covers all motions, while in lumbar dis- 
ease extension is alone rebelled against. 

The formation of abscesses usually occurs during the second 





Fig. 138. — Rotary lateral curvature of the 
spine. Female aged nine years. 



Fig. 139.— Rotary lateral curvature of the 
spine. Female aged nine years (Napier). 



year of the disease, but they may not be delayed so long, for in 
some instances they are found within five or six months from the 
time of the first symptoms. Such abscesses may occur with some- 
what acute symptoms, but this is very unusual, the typical forma- 
tion being a cold process. 

Hip-joint Disease. — There are three rather well-defined stages 
of this disease: the first an ostitis, and the second an arthritis. 
while the terminal stage is one of breaking down and absorption. 



468 



THE BONES AND JOINTS 



The first stage of ostitis may last only a few weeks or may per- 
sist for two years, with the average duration being four months, 
being followed by the stage of arthritis, which is also of indefinite 
duration, but which usually lasts for several months, and the third 
stage, which persists generally for years. 

It is the early recognition of the first stage that is of prime im- 
portance, the onset of which is usually very gradual. The symp- 
toms which are first noticed are generally lameness and some dis- 
inclination to walk on account of tenderness. These symptoms 
may persist in a mild degree for weeks, and are so trivial that they 

are usually neglected or misinter- 
preted, and it is only their per- 
sistence which attracts much atten- 
tion. At first the lameness is 
noticeable only in the morning 
upon arising, and becomes much 
less during the day. 

Soon the child complains of pain, 
and this is referred to the knee or 
to the hip. Such pain may have 
nightly exacerbations, but this is 
not always the case. Probably the 
pain is dependent upon stimulation 
of one of the articular branches of 
the obturator nerve. In any event 
it increases in severity, so that in 
time there are characteristic ' ' dart- 
ing pains" which occur at night and are so strongly indicative 
of hip disease. 

Up to this point in the development of the disease there is great 
danger of mistaking the condition for a strain of the joint, for mus- 
cular rheumatism, osteomyelitis of the femur, poliomyelitis, or 
caries of the lumbar region. The only method of avoiding such 
mistakes is by taking a careful history of the development of the 
symptoms; in every instance they are then distinctive enough 
to allow of no error. 

As the disease progresses the lameness, which was at first tran- 
sient, becomes a steady feature and an increasing one. Instead 




Fig. 140. — Lateral curvature of the 
spine (Napier). 



TUBERCULOUS DISEASES OF THE BONES 



469 



of being restless at night only, the child is now fretful and restless 
during the day also, until the first stage of the disease merges into 
the second stage of arthritis. 

If every child with lameness and tenderness was stripped and 
thoroughly examined before an opinion was expressed, many mis- 
takes would be avoided. The suspected hip should be compared 
with the healthy one and the general contour noted, also the pres- 
ence or absence of corresponding depressions and prominences. 
Quite early there may be a change in the hip's contour and the 
whole gluteal region is found to be flattened and broadened. The 
trochanter may be unduly prominent and the gluteal fold short- 
ened, or single in place of being double. When the limb is measured 
there may be shortening, but in nearly every instance there is atro- 




Fig. 141.— Examination of hip. 



phy of the thigh, so that the measurements are less, and the same 
is commonly true of the calf of the leg. 

After the examination just described, the child should be placed 
upon its back and every possible movement of the joint examined, 
proceeding, as before, by comparison with the sound limb. Usu- 
ally motion is limited in all directions, and this is bound to be so 
if the disease has persisted for a long time. Or if of very long 
standing, no motion at all is obtained. If the articular surfaces 
are crowded together, pain is the result ; but I believe that in most 
cases it is not the only result, for considerable injury may be done, 
and the procedure is rarely, if ever, justified. 

Then the gait and attitude must be studied. In walking the 
child favors the diseased joint, and throws the weight of the body 



470 THE BONES AND JOINTS 

as much as possible upon the sound limb. In standing the diseased 
side is also markedly favored. 

In the second stage the limb is permanently deformed. There are 
usually an e version of the foot, flexure and outward rotation of the 




Fig. 142.— Method of testing extension and flexion of the lower limb. 

thigh, and apparent lengthening, but if the limb be adducted, there 
may be apparent shortening so that it is necessary to measure in 
every case. There is no motion of the joint at this stage. Ab- 
scesses may form at almost any point. 

In the third stage the deformity is very marked, resulting from 




Fig. 143. — Testing the rotation of the hip. 

muscular spasm after the ligaments and bone have been absorbed. 
The position is similar to that which is observed in dislocation upon 
the dorsum of the ilium, so that there is considerable shortening, 
the thigh is strongly flexed, adducted, and with an inward rota- 



TUBERCULOUS DISEASES OE THE BONES 471 

tion. The foot is inverted. All this usually occurs gradually, 
but it may have rarely a sudden occurrence. Muscular atrophy 
is marked, and the position of the limb leads to certain compensa- 
tory changes to enable the child to stand and maintain an equi- 
librium. Lordosis and some degree of lateral curvature are gener- 
ally the result. 

As has been stated, the symptoms are so characteristic after 
the first stages that there is then practically no chance for mis- 
takes. 

Knee-joint Disease. — This disease usually affects children be- 
tween the ages of three and six years and is generally attributed to 
some injury. I mention this because so frequently the only his- 
tory is that an injury was received and the child has kept the knee 
bent slightly ever since and walks with a slight limp. Such is the 
early history of knee-joint disease. The little one does not usually 
complain of any pain in the beginning, but limps because the knee 
is bent. 

The great danger at this point is to consider the symptoms as 
due to injury, to synovitis, or to rheumatism. The history is usu- 
ally distinctive enough to differentiate all of these except the first, 
and that requires the most careful consideration. 

The affected joint is usually considerably warmer than the cor- 
responding joint. The outlines of the joint are fuller than they 
should be normally, and this is particularly noticeable upon either 
side of the ligamentum patellae, so that the natural depressions are 
lost. There is wasting of the limb both above and below the joint, 
and usually some slight fluctuation in the joint. In some cases 
fluid collects in a large quantity, but does not interfere with func- 
tion. 

Ankylosis, with the limb in a state of triple displacement-flexion, 
external rotation, and backward displacement of the tibia, take 
place when there is simple infection or suppuration. 

Ankle-joint Disease. — The symptoms are those which are 
common to all tuberculous joint diseases. In addition there is a 
swelling which is marked upon either side of the tendo Achillis. 
The child is capable of walking considerable distances, but does so 
with a limp, on account of the limited joint movement. Such a 
limitation is noticeable at first only under extreme flexion or ex- 



47 2 THE BONES AND JOINTS 

treme extension. The joint is usually hotter than its fellow, pain 
in not marked, and the leg is wasted, as a rule. 

Elbow- joint Disease. — This comes on very insidiously, because 
the pain and the functional disturbance of the joint are both very 
insignificant in the beginning. Usually the first thing to attract 
attention is the occurrence of swelling at the back of the joint, but 
this very soon extends around the joint, so that shortly a typical 
oval tumor is developed. Complete extension soon becomes an 
impossibility. 

Wrist- joint Disease. — In young children this is rare, but as 
the child approaches puberty it is more common. The disease 
comes on insidiously, usually involving the whole of the carpus. 
The joint becomes full and smooth in its outline, on both the palmar 
and the dorsal surfaces, and there is little difficulty experienced in 
extending it, although the hand is never used as freely as in the 
normal joint. Unfortunately, sinuses are usually formed, and 
generally quite early in the disease. The tendons and sheaths are 
generally involved in the tuberculous process also. 

Shoulder- joint Disease. — In some instances this runs its en- 
tire course with so few and so insignificant symptoms that anky- 
losis results without the child ever having given evidence of being 
very ill. In other cases the function of the joint is markedly 
affected, and there are internal rotation and adduction of the arm. 
Suppuration readily takes place and the abscess burrows downward 
along the biceps tendon in most instances. Pain is rarely a prom- 
inent symptom. 

Sternoclavicular Joint Disease. — In this pain is the early and 
the most prominent symptom, and is usually so acute that the child 
will assume a position which suggests a broken collar-bone; the 
elbow is instinctively supported, so that the weight is taken off 
the arm, and the head is inclined toward the affected joint. It is 
not long before the rather typical swelling appears over the joint ; 
it is oval in shape, with the long axis lying parallel to the clavicle. 
While the skin over the tumor is healthy, it is distended, and usu- 
ally is marked with enlarged veins. The tumor has a doughy feel. 

Sacro-iliac Disease. — This is so rare in childhood that it need 
hardly be considered, but in the early stages it may simulate hip- 
joint disease. The course is very slow. There is a distinct limp, 



TUBERCULOUS DISEASES OF THE BONES 473, 

and pain which is much more severe than in hip disease. The joint 
becomes quite swollen, and the atrophy which takes place in the 
buttock is early. While at rest the child is easier, for the pain is 
less or disappears altogether, but motion at once results in its pro- 
duction. Abscesses are common. The movements of the hip are 
all free, but examination usually shows thickening over the joint 
which is affected. Care must be exercised not to mistake the early 
symptoms for disease of the lumbar region. 

Tuberculous Dactylitis. — This not infrequently affects children 
during the second and third years of life, but may occur at any 





Fig. 144.— Double congenital anterior dislo- Fig. 145.— Congenital dislocation of right hip- 
cation of both hips. (Napier). 

time from the first to the fifteenth year. The metacarpus is most 
commonly affected. Usually the child so affected is a typical tu- 
berculous subject and the affection simply occurs as a part of a 
general infection with tuberculous disease. 

The enlargement of the bone is uniform, and it is not until sev- 
eral weeks that its maximum is reached. During this time there is 
no pain, but the movements of the bone are impaired. The skin 
is at first free from any involvement, but soon becomes thinned, 
and finally yields, so that a deep sinus is left with granulations. 
Syphilitic dactylitis is much less common than the tuberculous 



474 



THE BONES AND JOINTS 



form and occurs in a child who is of an entirely different type. The 
history of the two cases are very dissimilar also. The syphilitic 
form is at once amenable to proper treatment. 

Knchondromata run a much more protracted course and with- 
out any tendency to suppuration. They are recognized by their 
hardness and immobility, and the first feature is usually sufficient 
to distinguish them from tuberculous dactylitis. 



SYPHILITIC DISEASES OF THE BONES 

The bone diseases which occur in the course of syphilis might be 
well divided into two groups: those which accompany the early 
manifestations and those which accompany the later ones. 

Acute Epiphysitis. — This is the most common variety which 
accompanies the earliest manifestations of the disease. In nearly 




Fig. 146. — A characteristic posture in acute epiphysitis of the hip ; the limb of the affected 
side is drawn up to relieve tension. 



every instance the onset is very acute, so that the first thing which 
is noted is that the infant is unable to move the limb. The danger 
is in mistaking this condition for one of sudden paralysis. While 
the limb is absolutely motionless, the slightest attempt at passive 
motion is accompanied by intense pain. These symptoms almost 
always occur during the first six weeks of the infant's life, and often 
before any other manifestations of syphilis are present. 

It is not long before a swelling is noted at about the epiphyseal 
line ; this swelling is very noticeable in a superficially situated bone, 
but not so much so in a deeper situated one. There is generally 
quite a marked limitation of the enlargement to the end of the bone, 



SYPHILITIC DISEASES OF THE BONES 475 

but in those rare extreme cases it may involve much more of the 
limb. 

With appropriate treatment the duration of the disease is short, 
but if improperly treated, or if it goes on to suppuration, the course 
is much protracted. If scurvy occurred before the seventh month 
of life, the difficulty of differentiation between it and epiphysitis 
would be great, for there are so many features which are so com- 
mon to both, but scurvy is very rare before the seventh month 
(and in any event, never occurs as early in life as epiphysitis), 
and then, in addition, there is the clear history of some nutritional 
fault preceding the symptoms of the disease for a long time 
(usually the use of some proprietary food). 

The bones which are most often affected are the humerus, ra- 
dius, and ulna. 

Chronic Osteoperiostitis. — The typical changes due to this dis- 
ease are observed in the tibia. There is usually a forward curve of 
the anterior surface of the tibia, and the appearance of that bone is 
then saber-like; it looks as though the bone was compressed at 
the sides with an arch forward. This arch is only apparent, how- 
ever, for there is no actual curve of the shaft of the bone, the ap- 
pearance being due entirely to new-formed caseous tissue on the 
anterior surface. There is some liability of mistaking such a con- 
dition for rachitis, but in rachitis there is a distinct curve and not 
simply a unilateral thickening, and, further than this, the rachitic 
curvature occurs when the child begins to walk or stand. 

The new bone deposit is the result of a specific periostitis, and 
therefore in the beginning it is accompanied by much pain. The 
pain is worse at night and is the earliest symptom, being present 
usually for a considerable time before the occurrence of other symp- 
toms. When thickening occurs, the pain usually is much relieved 
or altogether disappears. There are always atypical cases, and 
in these the pain may be such as to be noticed onlv when the child 
is freely handled, and in these instances the diagnosis is made by 
the pain being worse at night, tenderness being always more or 
less present, and the other manifestations of syphilis being present. 

If the cranium is affected, the usual form is that of a gumma tons 
periostitis. These gummata are half -spherical, limited swellings. 
which are quite painful. In the commencement they are solid 



476 the: bones and joints 

but soon there is a distinct fluctuation felt, and about the same 
time they become more or less adherent to the skin. 

It is rather unusual for any other disease than syphilis to cause 
localized disease of the cranial bones, so that if it is possible to 
eliminate injury as a cause, such disease is almost certainly syphil- 
itic. The various bone lesions of syphilis are readily mistaken for 
the lesions which occur in some cases of scrofulosis, but in syphilis 
the whole history is different, and in scrofulosis it is the short bones 
and the epiphyses of the long ones that are most commonly affected. 
Pain during scrofulosis is usually very slight or absent altogether, 
and the bone itself is not enlarged, the swelling being largely 
edematous. 

The result of treatment is of immense value. 

Syphilitic Dactylitis. — This is not a frequent disease, but the 
symptoms somewhat closely resemble the tuberculous form, usually 
going on to suppuration and necrosis. The diagnosis must distinguish 
between the two forms of the disease ; they occur in entirely differ- 
ent types of children, and the syphilitic form is very amenable 
to treatment, while the tuberculous is not. Tuberculous dactyl- 
itis occurs almost invariably as a part of a general infection in a 
typically tuberculous child. 



THE LYMPHATIC GLANDS 

In perfectly healthy children with an average amount of devel- 
opment of the tissues it is not possible to palpate the lymphatic 
glands. 

Acute enlargement of the lymphatic glands is the usual accom- 
paniment of some of the acute 
infectious diseases. In this 
particular it is not simply an 
accidental occurrence, but 
there exists a well-established 
connection between the loca- 
tion of the adenitis and the 
disease with which it is asso- 
ciated. Such an adenitis 
may prove of value in diag- 
nosis, if its location and ex- 
tent are considered. 

Although no age is im- 
mune, acute enlargement 
shows a special preference 
for the developing period. 
Any lymph-node of the 
body may become the site 
of an enlargement, but the 
glands most often affected 
are the cervical, both an- 
terior and posterior to the sternomastoid muscles, beneath the 
angle of the jaw and under the chin. 

It is not common for a solitary gland to be affected, but the en- 
largement shows in a group of nodules which are freely movable 
and somewhat definitely outlined. Sometimes it happens that 
a group will enlarge at once, with periglandular infiltration, form- 
ing a tumor in which separate nodes cannot be made out. The 
skin covering this swelling may be shining and tense. 

477 




Fig. 147.— Location of lymphatic glands, 
explanation, see page 479.) 



(For 



478 



THE LYMPHATIC GLANDS 



The course of an adenitis depends upon the nature of the infec- 
tious microbe and upon the resisting powers of the child. Staphy- 
lococcus and streptococcus infection may lead to suppuration and 
breaking down of the glands, but suppuration is not the rule. The 
usual course is gradual subsidence within a period of two weeks. 

Aside from the diagnosis of an adenitis, there should be a recog- 
nition of its cause, and when the enlargement is in the cervical 
glands, this may be found to be some faucial, nasal, pharyngeal, or 

aural disease. Disease of these 
latter situations often explains 
the persistence of cervical en- 
largement after diphtheria and 
scarlet fever. Inguinal adenitis 

J may accompany vulvovaginitis 
in girls, or preputial or urethral 
lesions in boys. On the other 
hand, it usually is associated 
with any suppurating lesion of 
the lower extremity. 
To avoid repetition, it may be 
stated, as a general fact, that 
adenitis is not an unusual accom- 
paniment of infected lesions and 
abrasions, and that the location 
of the lesion determines the 
situation of the affection of the 
glands. 

Chronic Enlargement. — This 
indicates some serious derange- 
ment of the general nutritive processes or some catarrhal lesion. 
In any event, the cause should be sought for, and this will usually 
be found either in scrofulosis, tuberculosis, leukemia, or in some 
general malnutrition. 

Occasionally, during infancy, numerous small, hard, painless 
glands can be palpated in the neck, the groin, or the axilla, and 
such a condition is indicative of scrofulosis. If, in addition to 
this, the infant is anemic and weak, and the spleen is noticeably 
enlarged also, one may justly suspect tuberculosis. 



Fig. 148.— Location of lymphatic glands. 
(For explanation, see page 480.) 



ENLARGEMENT 479 

Of course, in considering the presence of such glands, acute dis- 
ease must be excluded and the chronicity established. There is 
a very marked proneness of chronically enlarged glands to exhibit 
acute exacerbations, and this is expected, as it is only one other 
evidence of the susceptibility of children with chronically enlarged 
glands to infection from trivial causes. 

THE LOCATION OF LYMPHATIC GLANDS AND THEIR DRAINAGE 

AREAS. 
(From Curnow and Treves.) 

. , ' > Posterior half of the head. 

Mastoid, J 

Parotid Anterior half of head, orbits, nose, upper jaw, upper 

part of the pharynx. 

Submaxillary Lower gums, lower part of face, front of tongue, and 

mouth. 

Suprahyoid Anterior part of tongue, chin, and lower lip. 

Superficial cervical . . Exterior ear, side of head, and neck and face. 

Retropharyngeal Nasal fossae and upper part of pharynx. 

Deep cervical Mouth, tonsils, palate, lower part of pharynx, larynx, 

posterior part of tongue, nasal fossae, parotid and sub- 
maxillary glands, interior of skull, and deep parts of 
the head and neck, upper set of lymph-glands, lower 
part of neck, and joining axillary and mediastinal 
glands. 

Supracondyloid Three inner fingers. 

Axillary Upper extremity, dorsal and scapular regions, front and 

sides of trunk and chest. 

Anterior tibial, ^ Deep lymphatics of the leg, and receive some vessels 

Popliteal, J ' from the skin of the leg and foot (chiefly outer side). 

Inguinal Femoral set : Superficial vessels of the lower limb, and 

partly of buttock and genitals, perineum. Horizontal 
set: Abdomen below the umbilicus, buttock, and 
genitals. The deep vessels of the lower limb go to 
the deep glands along the femoral vein. 

Iliac The pelvic viscera and the deep vessels of the genitals 

partly. 

Lumbar All the lower glands, uterus, testes, ovaries, kidneys. 

Sacral The rectum. 

THE SITUATION OF THE PRINCIPAL LYMPHATIC GLANDS AND THE 
CONDITIONS WHICH ARE SUGGESTED WHEN THEY BE- 
COME ENLARGED OR TENDER ACUTELY. 
1. Diseases of the ear (especially 2. Mastoiditis and infections and 
eruptions); eruptions about the eruptions affecting the scalp. 

face; and occasionally during 3. Infections of the chin, the tongue, 
parotiditis. and the lower lip. 



480 



THE LYMPHATIC GLANDS 



4. Infections of the mouth and 
teeth, stomatitis, rubeola, and 
rubella. 

•5. Infections of the tonsils, in the mild 
attacks of scarlet fever and at 
first in variola. In severe scar- 
let fever 5, 6, 7, and 8 may be 
much affected. 

•6. Pharyngeal infections and inflam- 
mations, therefore in retro- 
pharyngeal lymphadenitis. Also 
in severe scarlet fever and in 
rubeola. 

7. Infections of the scalp and severe 

scarlet fever. 

8. Infections of the scalp and severe 

scarlet fever. 
{During the course of diphtheria, 4, 5, 
6, 7, and 8 may become promi- 
nently enlarged, so that the 



whole neck appears badly swollen 
and tender.) 
9. Infections of the neck and oc- 
casionally during the course of 
diphtheria. 

10. Infections affecting the arm, the 

axilla, and the upper portions of 
the chest, anteriorly and pos- 
teriorly. 

11. Infections of the hand, and es- 

pecially of the three inner fingers. 
Quite frequently this is enlarged 
during the course of a syphilitic 
eruption. 

12. Infections affecting the lower 

limb, and particularly the thigh 
and sometimes during the course 
of syphilis. In rare instances 
these glands are affected in ru- 
bella. 



THE ACUTE INFECTIOUS EXANTHEMATA 

The diagnosis of the cutaneous eruptions which accompany 
and are an integral part of the acute infectious diseases cannot 
properly be taught by description, no matter how well chosen 
the words or how skilfully executed the plate to illustrate them. 
It is only by a wide experience that one is able quickly and 
correctly to distinguish them when the course is not typical. If 
certain well-established facts are borne in mind, the diagnosis 
is much simplified, and the failure to take the time and pains 
which are necessary to elucidate these will lead one into various 
errors in the diagnosis. These established facts are as follows : 

(a) All diseases of this class are contagious (rubeola, rubella, 
scarlet fever, variola, varicella). The time taken clearly to bring 
out the history of exposure to one of these diseases is never wasted. 
The very prevalence of the particular disease in question is often 
the first thing that leads one to suspect the real cause of the 
first indefinite symptoms and aids in an early diagnosis. This 
becomes particularly forcible when one or more members of a 
particular family have been previously and recently affected. 
To be able to take a clear history implies that there is an intimate 
knowledge of the various periods of incubation, for without that, 
even with a history of exposure, one would not know when to 
look for the first symptoms. 

(b) There is a distinct incubation period. This period is referred 
to as an incubation period because, after a known exposure, there 
is a varying time in which there is an absence of all symptoms, 
and while in some of the diseases this time is very definite, in 
others it is less so. The various incubation periods are as follows: 

Rubeola: From the time of exposure until the first catarrhal 
symptoms appear there is usually an interval of eleven days: 
then follows the stage of invasion, which lasts for about throe 
days, at which time the eruption may be detected in the mouth 
a short time before its appearance upon the cutaneous surface. 

Rubella: From fourteen to eighteen da vs. 
31 481 



482 THE ACUTE INFECTIOUS EXANTHEMATA 

Scarlet fever: From twenty-four hours to five days. The 
shorter period is the usual one. 

Variola : The average is twelve days. 

Varicella: Fourteen days. 

All these periods may be subject to slight variation. 

(c) A certain immunity is acquired by previous infection. In 
all the acute infectious exanthemata a certain immunity is 
acquired when the patient has been once attacked by the disease. 
Whatever the explanation of this immunity may be, it clearly 
involves some systemic change which usually persists throughout 
life. 

Popularly, this is not so, and case after case is recited by the 
layman to show the possibility of second, third, and more infec- 
tions with the same disease. This is brought about largely by 
hasty diagnosis, so that in the presence of a history of previous 
infection a very full history of that illness must be obtained. 
In the case of scarlet fever the questions should be such as to 
determine the length and severity of the illness and whether any 
sequels developed, for erythemas are often diagnosed as scarlet 
fever, and so mislead as to second invasions. 

An attack of urticaria is frequently called rubeola, as is also 
rubella. Rashes caused by the ingestion of certain articles of 
diet and of medicines occasionally lead to hasty and incorrect 
diagnosis, with subsequent uncertainty as to the occurrence of 
disease. 

(d) All have a more or less typical course. This might be 
divided into stages: the incubation, which has been referred to; 
the prodromal, which commences with elevation of temperature; 
the eruptive; the declining; and convalescence. 

A cutaneous eruption, dependent upon any specific infectious 
cause, is influenced by the general condition of the skin of the 
person affected, as well as by its structure. To distinguish these 
differences there must be a consideration of the age of the child 
(the younger the child, the more tender the structure of the skin, 
as a rule), the general state of nutrition (a poorly nourished 
infant means a poorly nourished skin), the cleanliness of the skin, 
idiosyncrasies toward the development of erythemas and urti- 
caria. 



RUBEOLA 483 

In one child we will find a very tender skin with scarcely visi- 
ble glands, but with a capillary circulation which is so superfi- 
cial that it imparts an unusual glow to the parts, while in another 
child the reverse may be true. The skins of both children should 
not be expected to react exactly alike under the influence of 
cutaneous eruption. 

Every eruption should be very minutely examined, and pref- 
erably in good sunlight (a small vest-pocket magnifying glass 
being a valuable aid, and at times a necessity), and the more 
recent efflorescences must be observed in order to determine the 
original form of the eruption. When these are seen, then it is a 
simple matter to compare the further development of the rash. 

The diagnosis should never depend upon the character of the 
eruption alone, but the time, manner, and distribution of the 
rash and the associated symptoms must all be considered. This 
is particularly true if the disease seems to differ from the usual 
type. It is quite necessary that the diagnosis be made as early 
as possible, so that protection may be afforded to those who may 
be brought in contact with the case ; therefore it is very impor- 
tant that the symptoms of the prodromal period be prominently 
kept in mind. 

In rubeola there is usually a distinct prodromal stage of three 
days with well-marked catarrhal symptoms, primarily of the upper 
respiratory tract. In scarlet fever the prodromes last for one 
or two days, with an unusual increase in the rate of the pulse, 
vomiting, and faucial involvement as the prominent symptoms. 
In rubella there is usually a complete absence of prodromes. 

In addition to this, whenever there is a suspicion that a disease 
is contagious, efforts should be made to isolate the patient until 
the diagnosis is fully established. 

RUBEOLA 

The preeminent symptoms of rubeola are fever, catarrh of the 
upper respiratory passages and of the eyes and an eruption. 
The disease rarely occurs more than once during a lifetime, so 
that one attack affords a certain amount of immunity from 
another. There seems to be a partial immunity which exists 
for the first five months of life, so that the disease is an unusual 



4 8 4 



THE ACUTE INFECTIOUS EXANTHEMATA 



occurrence before that time. The apparent immunity of adults 
is brought about by the occurrence of an attack during earlier 
life. 

The incubation period is generally free from any deviations 
from normal conditions, but there may be slight temperature 
changes. If these are present, they consist of a morning eleva- 
tion of one degree and an evening rise of less than two degrees 
Fahrenheit, as a rule. When such an elevation of the temperature 
occurs, there is always an associated slight catarrhal condition 
of the conjunctiva, which persists only for a brief period and 
disappears before the development of the usual prodromes of 

the affection. If the 
temperature rise exists 
alone, then it is due 
to some other condi- 
tion besides the infec- 
tion. 

The diagnosis of 
measles is unfortun- 
ately uncertain before 
the appearance of the 
characteristic eruption 
upon the skin, with 
the one exception that 
if we are able to dem- 
onstrate the Koplik 
spots, the diagnosis is at once made positively. During the time 
that measles is epidemic, or when there has been a known exposure 
to the contagion, the onset of a catarrh with involvement of the 
eyes should at once excite suspicion. During the catarrhal stage 
of the disease there are coryza, slight nasal discharge, usually 
more or less sneezing, disturbed sleep from the occlusion caused 
by the swollen mucous membranes, and occasionally, in infants, 
epistaxis. To these are added, as a rule, a sense of pain or pres- 
sure in the eyes (a symptom which is very unusual in all other 
coryzas), and this results in rubbing of the eyes on account of 
the irritation. Lacrimation is more or less in evidence, and 
photophobia may be severe, so that the child buries its face in 



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Fig. 149.— Temperature ( ) and pulse ( ) in 

rubeola. Child three years old. 



RUBEOLA 485 

the pillow in the effort to avoid light. The conjunctiva is injected. 
During this stage cough is somewhat characteristic and is dry, 
harsh, and paroxysmal. Even when the cough is of mild degree, 
the voice is muffled or hoarse from the first onset of the catarrhal 
stage. 

It is just at this time that the search for the presence of Koplik's 
spots is of most value in the diagnosis. The mucous membrane 
of the cheek should be carefully examined, for it is only with 
much diligence that the fine eruption can be detected at this 
time. The best illumination is sunlight coming directly from 
the side, or diffused daylight. It is very difficult to see the spots 
by gaslight. 

The spots are found upon the inner surfaces of the cheeks, 
behind the angle of the mouth, and have the appearance of little 
specks of lime sprinkled upon the mucous membrane and upon 
a reddened base. They are raised above the surface, are of a 
bluish-white or yellowish-white color, and cannot be wiped off. 
Such spots do not appear as prodromes in any other cutaneous 
rash which resembles measles, so that they are valuable aids to the 
diagnosis. 

During this catarrhal stage influenza may be suspected as the 
cause of the catarrh, the cough, and the general distress, but the 
doubt cannot exist long, as a rule, for by the second or third day 
the prodromal eruption is observed in the mouth. It sometimes 
happens, however, that this prodromal rash does not develop 
frankly, and then the differential diagnosis is more obscure. In 
favor of influenza we find that the primary rise of the temperature 
is less, the photophobia is not so marked, and there is no appre- 
ciable fall of the temperature on the second day. 

It must be remembered that all the typical symptoms of 
the catarrhal stage may not be present, but that only one or 
more may be in any prominence, so that a disturbance of the 
general good condition of the child is evidenced, but without 
apparent cause. 

While the catarrhal symptoms persist for a week or a little 
more (that is, until the eruption is fully developed^, and begin 
to subside coincident with the fading away of the rash, the symp- 
toms of the invasion reallv last for only three days, for at the end 



486 



THE ACUTE INFECTIOUS EXANTHEMATA 



of that time the eruption appears in the mouth. On the mucous 
membrane of the palate there appear individual deep-red ser- 
rated spots, inside of which the solitary and swollen follicles are 
observed as individual nodules. Such precede the cutaneous 
eruption by a brief period. At the end of the third or the begin- 
ning of the fourth day the first macules appear upon the skin 
of the face (about the nose, the lips, and the chin), from which 
point there is an extension to the rest of the face, the neck, the 
upper trunk and arms, the lower trunk, buttocks, thighs, fore- 
arms, legs, and feet, and usually in the order named. This 
whole process of extension (from face to feet) occupies about 

thirty-six to forty- 
eight hours. 

The first appear- 
ance of the spots is 
peculiar ; they are 
small (pinhead size), 
round, not raised 
above the level of 
the skin, and are of 
a light red color. 
They rapidly become 
larger, much more 
irregular in shape, of 
a deeper red, and 
with a tendency to 
coalesce. When they attain their typical development, they are 
irregular, serrated, crescent-shaped macules inside of individual 
ones, and in the center of each spot one may detect by sight or 
by touch a small nodule of a redness similar to that of the spot 
itself. In the larger macules there may be as many as four such 
nodules. 

These nodules correspond quite closely to the sebaceous folli- 
cles and the hair-follicles, and as the glands secrete more abun- 
dantly than normal, the eruption has a slightly greasy feel. In 
its full development the macule is raised above the level of the 
skin. 

At the acme of the eruption the entire skin from head to feet 



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Fig. 150.— Temperature ( ) and pulse (- 

rubeola. Child six years old. 



-) in 



RUBEOLA 487 

is covered with the closely crowded individual points of the rash, 
and for a short time the eruption remains at its height. The 
hairy portions of the body are covered with eruptions as well as 
other parts, but the soles of the feet and the backs of the hands 
are generally most affected. 

The usual appearance is sometimes altered (and this is par- 
ticularly so upon the back) when the macules coalesce com- 
pletely, forming large groups, and this gives the skin the appear- 
ance of being covered with a connected eruption, which appearance 
is quite distinct from the spotted skin of the ordinary rash. 

It is not infrequent that the eruption becomes slightly hem- 
orrhagic, and in that case the color is much darker ; and if consider- 
able areas are involved, it becomes a dark bluish-red, which 
finally fades into a greenish or yellowish hue. Its main impor- 
tance is in the fact that it might hastily be mistaken for a general 
cyanosis, which, when it occurs during the course of rubeola, is 
of evil import. 

With the full development of the eruption the disease reaches 
its height, and at this time the temperature is almost continuously 
high (io3°toio5°F.) and the nervous system more or less affected. 
Anorexia is so marked that it is usually complete; there is great 
irritability, sometimes delirium, and the catarrhal processes are 
all exaggerated. The dry, harsh cough is very troublesome, the 
eyes are very sore, there is marked photophobia, and the secre- 
tion from the nostrils is so irritating that it excoriates the upper 
lip. The physical examination will almost invariably reveal the 
presence of bronchitis of the larger tubes. The lymph-glands 
of the neck, of the axilla, and of the groin may become consider- 
ably enlarged at this time, and at times are more or less painful. 

It is fairly characteristic of the disease that its severity is 
progressive with the development of the eruption, and when that 
is at its height, the disease is at its acme. The change for the 
better comes quite suddenly. At the time that the child is suffer- 
ing most from fever, the catarrh, the cough, and general discomfort . 
there comes a sudden relief, so that within a few hours the little 
one appears to be almost entirely well. He is inclined to play, 
the appetite returns, the mind is clear, the fever almost if not 
entirely gone, the sleep is undisturbed, the cough becomes loose. 



488 



THE ACUTE INFECTIOUS EXANTHEMATA 



and the whole picture is of rather sudden and marked improve- 
ment. 

Here it is that there is danger of considering the disease at an 
end, for the child appears to all to be so well ; but that the disease 
in a way still persists is shown by the slow clearing up of the 
catarrhal symptoms and the fact that it is during this period 
that the sequels are apt to develop. The conjunctiva still is 
moist with the secretion, the cough slowly disappears, and the 
voice remains hoarse or more or less thickened for several days. 
The skin remains for some time sensitive to the influence of cold, 



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Fig. 151.— Temperature chart of rubeola of moderate severity in a child of four and one-half 

years. 



and sweating may be quite marked. The pulse is abnormally 
slow and exhibits some irregularity. There is no positive indi- 
cation by which we may feel assured that there is a complete 
return to health, and the desquamation which takes place is 
also uncertain in its duration. Several days at least must inter- 
vene before we can consider the child well. 

The fever in measles is not of a constant type, and in individual 
cases the character of the temperature curve may vary. However, 
in most of the cases the fever is remittent in the first days, is at 
its highest elevation during the full development of the eruption, 
and exhibits a rapid fall after the complete development of the 



RUBEOLA 489 

rash. There are, therefore, usually two maximums and a sudden 
termination with a short fastigium. The first maximum is 
observed upon the first day of the prodromal period ; the second, 
upon the first or second day of the eruption. If the initial maxi- 
mum is low, then one may predict with safety that the attack 
will be light. Fig. 151 shows a temperature chart of a case of 
measles of moderate severity. 

The diagnosis is not difficult when the case is quite well devel- 
oped or if it follows a somewhat typical course. The possibilities 
of error in diagnosis in the first stages, when the fever and catar- 
rhal symptoms are the prominent ones, have already been referred 
to. 

In the early eruptive stage rubeola may readily be mistaken 
for variola, but this error is not so apt to occur in childhood as 
it is in later life. In children the prodromal eruption in the 
mouth and the catarrhal symptoms of rubeola are usually both 
well developed, and both of these are absent in variola, so that 
even in those exceptional cases (which so often lead to error in 
adult life) where the macule of rubeola is infiltrated, intensely 
red, and glistening, the diagnosis is usually easy. With such a 
modification of the eruption and the catarrhal symptoms quite 
mild, the difficulty would be much greater, so that the history 
of a recent and successful vaccination would be of value. Even 
so, the decision may have to be postponed for another twenty- 
four hours, when one is able to make further distinctions; the 
variolous eruption is much slower in its development and is less 
abundant at first than the rubeolous spots, so that very numerous 
papules on the face, being quickly developed, would be in favor 
of a diagnosis of rubeola. 

When variola is developed sufficiently to have a wide-spread 
distribution, one is always able to find some vesicles, although 
they may be small, while the color of the papule is pinkish, in 
contradistinction to the more reddened spot of rubeola. Oc- 
casionally rubeola maintains its primary macular character, and 
the eruption may then resemble scarlet fever to a considerable 
extent. Unfortunately for the diagnostician, in most such cases 
the catarrhal symptoms are not prominent except in the pharynx, 
so that a further difficulty is added in the differentiation. 



490 the: acute infectious exanthemata 

However, we recall that the eruption in rubeola is as decided 
about the nose, lips, and chin as it is elsewhere upon the face, 
and, further than that, this is usually the first part invaded. 
In scarlet fever these parts are usually spared, so that the con- 
trast between the clear portion and the parts covered with the 
eruption is itself an aid in the diagnosis. If pressure be applied 
over the reddened area, the small reddened points reappear when 
pressure is removed. The measles eruption, even when confluent, 
is of a uniform red color without any points of a more intense hue. 

Rubella may occur with the eruption at first being "measly," 
and under those conditions may be mistaken for rubeola. The 
rash of rubella has the character of the rubeola eruption, but 
is more pallid, and the eruption is much quicker in its develop- 
ment, spreading all over the body within twenty-four hours. 
The same distribution occupies two or three days in measles. 
For several days preceding the eruption of rubella there is usually 
some tenderness and enlargement of the posterior cervical glands 
(in rubeola, if this occurs at all, it is late in the disease), the 
catarrhal phenomena are slight or absent, the fever insignificant, 
and there is no photophobia. Upon the positive side of rubella 
we observe the glandular enlargement and sore throat, the first 
being quite uncommon and the second rare in rubeola. 

There are many drugs which, when administered to children, 
will cause the appearance of a diffuse eruption. Antipyrin is 
the one which is most apt to cause an eruption in children which 
resembles measles. When the history of its administration is 
obtained, the diagnosis is easy, for there is an entire absence of 
the usual associated symptoms of measles. 

In some few cases of epidemic cerebrospinal meningitis the 
eruption is profuse enough to exhibit a certain amount of simi- 
larity to rubeola, but usually the spots are localized upon the 
extremities and sparsely upon the trunk. The phenomena which 
are associated with inflammation of the meninges are usually 
sufficient to at once make the distinction plain. 

The eruptions which at times develop during septic affections, 
and which may markedly resemble the eruption of rubeola, are 
differentiated by a study of the associated symptoms, which 
makes the diagnosis self-evident. 



RUBEOLA 



491 



Deviations from the Usual Course of the Disease. — It is 
quite necessary that the principal deviations from the usual 
course of rubeola be remembered, for otherwise the diagnosis 
would be made more difficult and at times impossible. 

During the period of incubation there may be slight elevations 
of the temperature (one degree in the morning and less than 
two in the evening) with an associated very slight catarrh which 
involves the eyes and nasal passages. The result of this is that 
the history is obtained of slight catarrh with cough and some 
malaise existing for several days. The chance of error comes in 



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Fig. 152. — Temperature ( ) and respiration ( ) in rubeola with bronchopneumonia. 

Child two years old. 



considering the real onset of the severe catarrhal symptoms as 
an acute exacerbation of a previously existing catarrhal cold. 

During the stage of invasion the symptoms may be very slight, 
and the history obtained is that the child was perfectly well up 
to the time of the appearance of the eruption. The danger of 
error is in considering such cases as rubella, for, as a rule, with 
mild catarrhal symptoms the whole course of rubeola is mild. 

The stage of invasion may come on with most severe symptoms 
(continued high temperature, convulsions, intense catarrhal 
symptoms, vomiting, coma) and may last for several days. The 
possibilities of error are great and the mistakes varied. The 
appearance of the rash decides the case. 



492 THE ACUTE INFECTIOUS EXANTHEMATA 

The stage of invasion may be abnormally prolonged (five, 
six, or seven days), with a remittent type of fever throughout. 
But with this course there is always the development (partial) 
of some of the spots somewhere upon the body, just at the time 
that the eruption should be well developed. Of course, if a 
thorough examination has been neglected, these will not be noted. 

The catarrhal symptoms may be intensely developed, so that 
the child exhibits a dyspnea, and the mucopurulent secretion 
in the nose is so profuse that the child suffers great discomfort. 
This may be accompanied by profuse epistaxis. In a short 
time the eustachian tube and the larynx may become affected. 
I have seen such cases diagnosed as diphtheria, and that seems 
to be the chief danger. When the frequency with which measles 
is associated with diphtheria is remembered, it is little to be 
wondered at that the diagnosis sometimes is made of both diseases 
existing together. The catarrhal symptoms may be slight and 
associated with a simple or a purulent inflammation of the glands 
at the angle of the jaw. 

The eruptive stage may also exhibit deviations. 

The course may be very mild and the eruption slight, or, in 
other instances, remaining but a few hours or only one day. 
In rare instances there may be no eruption at all. 

Sometimes the senses are markedly affected from the very 
start, even though the disease runs a moderate course in all other 
particulars. During the period of invasion the child is apathetic 
and somnolent. On the fourth or fifth day a few macules may 
appear, but they are pale and indistinct and confined largely 
to the trunk. The child may have a hunted look, and somno- 
lence usually alternates with mental irritability. After a few 
days general convulsions supervene, and may last for hours, 
terminating life. In such cases the eruption may follow one of 
two courses: remain undeveloped permanently, or remain so 
for a few days and then develop rapidly as death approaches. 

"The measles have struck in " — that is the greeting which one 
sometimes hears, and this is the way in which it appeals to the 
lay mind. Such a happening usually occurs during the first 
year of life, and the very first indication of anything unusual is 
during the stage of invasion: the child suffers from more or less 



RUBEOLA 



493 



dyspnea. Other than this there is nothing unusual, ana the erup- 
tion develops in the regular order up to a certain point, when its 
development is suddenly arrested and a cyanotic hue is noticed 
instead of the usual red. The child then fails rapidly, and the 
whole picture is one of an extreme lung and bronchi involvement. 
The heart grows weaker rapidly, diarrhea usually is profuse, and 
while the signs of bronchopneumonia are gradually becoming 
more and more evident, the fatal issue is reached (usually with 
convulsions) about the eighth day. 

Some few cases have been reported of a relapsing eruption, 



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rig. 153.— Temperature (- 



-) and respiration ( ) in rubeola with bronchopneumonia. 

Child three years old. 



but such are exceedingly rare, if we judge by the literature on 
the subject. 

Deviations during convalescence are many and important. 

The defervescence may be incomplete or there may be a sub- 
sequent rise of temperature which is considerable, both of which 
may indicate simply an irregularity in the course of the disease 
or the occurrence of a complication. The catarrh of the eyes 
may persist and finally eventuate in an ophthalmia which may 
prove destructive to sight. Persisting in the nose, the catarrh 
may lead to ulceration of the mucous membrane. The eustachian 
tube may become involved from an extension of the infectious 
process in the pharynx, and otitis media result. At the time 



494 TH E ACUTE INFECTIOUS EXANTHEMATA 

of defervescence a more or less profuse diarrhea may occur, and 
this is particularly true of nurslings, and convalescence is thereby 
much prolonged. 

The complications may be varied. The sequels are many, 
and it is needful to mention the more important of these, as their 
recognition may be influenced by their occurrence during the 
attack of rubeola. The most common are ophthalmia, aphthous 
stomatitis, chronic otorrhea, noma, inflammations of the bronchi 
and the lungs, rheumatic and cardiac affections, catarrhal laryn- 
gitis, and tuberculosis. 

RUBELLA 

In a very large measure it is the eruption upon the skin which is 
of most value in a differential diagnosis of the various acute infec- 
tious exanthemata, and this is particularly true of rubella, on ac- 
count of the few associated symptoms of the affection. 

There is no typical uniformity about the rash of rubella. At 
times it consists of large, slightly elevated papulo-macules of a 
rose-red color. In such instances the greatest similarity is to the 
eruption of rubeola, but the latter is of a much darker hue. In 
still other cases the eruption is small, so that at a hasty examina- 
tion the resemblance to scarlet fever may be marked, but in ru- 
bella the finely punctiform eruption which is observed in scarlet 
fever is never seen. 

The individual macule usually has an irregular serrated limita- 
tion, and the macules so distributed that in some parts of the body 
there is a considerable stretch of normal skin in between. There 
is but a slight tendency to grouping. The distribution of the erup- 
tion is, as a rule, from the head and face downward, but at times 
it is first observed upon the chest and arms. Below the knee the 
macules are but scarce. 

Regardless of the eruption itself, there are two clinical features, 
of the affection which are of more or less import : the enlargement 
of the superficial cervical glands and splenic enlargement. 

The lymphatic enlargement is not severe, but moderate or slight, 
and is present usually for several days preceding the eruption. It 
is frequently the very first indication which we have of the onset 
of the affection. It has a distinct diagnostic value, and particu- 



rubella 495 

larly a differential one, for in measles lymphatic enlargement may 
occur late in the disease and is dependent upon the severity of the 
catarrh, while in rubella it is of primary occurrence. 

The splenic enlargement is but moderate, but is present from the 
onset to the end of convalescence. 

Rubella may run its entire course without any elevation of tem- 
perature, but usually there is a slight rise (ioi° to 102 F.), which 
is highest at the onset of the affection and disappears by a rapid 
lysis. In rare instances the temperature is markedly elevated, 
with the usual associated symptoms of such a disturbance. 

The average duration of the eruption is three days, but occasion- 
ally it lasts for four, and not infrequently a shorter period (one or 
two days) is noted. The fading of the rash is usually in the order 
of its appearance and is generally rapid. 

When the rash of rubella simulates that of rubeola, the differen- 
tial diagnosis is suggested by the paler tint of the rubella eruption, 
by its more rapid appearance (developing within twenty-four to 
thirty-six hours, whereas in measles two or three days are required 
for a general distribution), and in the absence or mildness of asso- 
ciated symptoms of elevated temperature and catarrhal inflam- 
mation of the upper respiratory organs. The history of exposure 
is of immense value, for it is the sporadic cases or those which occur 
early in an epidemic that offer the greatest difficulties in diagnosis. 

As has been stated, the eruption sometimes resembles that of 
mild scarlet fever, but the eruption in rubella shows a special pref- 
erence for early development about the nose, chin, and lips, the 
points which are almost invariably spared by the scarlet fever 
rash. In the beginning of scarlet fever vomiting is common, as is 
also painful deglutition, both of which are very unusual in rubella. 
In rubella the eruption is usually the first symptom, with one ex- 
ception — the lymphatic enlargement. Both in rubeola and in 
scarlet fever before the appearance of the eruption there are more 
or less clearly defined symptoms, which are suggestive. 

If antitoxin has been used for the control of diphtheria or for 
immunization, it may result in a rash which consists of flat mac- 
ules and papules, and when rubella is epidemic, this rash may create 
some confusion. However, we have the history of the use of the 
serum to arouse our suspicions, and unless a refined serum has been 



49 6 TH 3 ACUTE INFECTIOUS EXANTHEMATA 

used, the chance of subsequent eruption is large. The macules 
are usually larger than those of rubella and irregularly distributed. 
Generally speaking, it is rarely safe to consider a case as rubella 
unless the disease is epidemic or typical. Even then the chances 
of mistaking mild cases of scarlet fever and of rubeola for rubella 
are great, and there is no question but that many times the error 
is made. The cases which simulate scarlet fever are the most try- 
ing ones. It is the part of wisdom in such instances to consider 
the case as one of scarlet fever until the case is so advanced that 
a positive diagnosis is possible. 



SCARLET FEVER 

Every child who is taken suddenly ill with vomiting, sore throat, 
and high temperature should at once be isolated as a scarlet fever 
suspect until the contrary may be proved to be the case. 

Of all the modes of onset, that which is accompanied with vomit- 
ing is most common, and in a case of moderate severity the act is 
repeated several times during the early hours of the disease. In 
children under three the vomiting is generally associated with 
more or less profuse diarrhea which lasts for a day or two. Ac- 
cording to the time of the last meal, the vomiting consists of food, 
mucus, or bile-stained fluid. 

In children over the age of five (and particularly in those over 
ten) an initial chill may be present. There may also be a com- 
plaint made of several hours of general malaise, cephalalgia, irri- 
tability, and muscular pain, preceding the onset. 

From six to twenty-four hours after the first symptoms of illness 
the child may complain of pain in deglutition, but this is only so 
as the child becomes older, young children making no such com- 
plaint. When the examination of the oral cavity is attempted, 
it is found that the tongue is white-coated and the filiform papillae 
are reddened; the palatine mucous membrane is very noticeably 
congested, showing small but distinct macules; the tonsils are en- 
larged and deeply reddened, and there may be, even at this time, 
the presence of reddish, yellowish striae upon their surface. 

The temperature is always elevated, and usually to a consider- 
able degree (103 to 105 F.), and this febrile condition persists for 



SCARLET FEVER 497 

from eight to ten days. Even during the first twenty-four hours 
of the fever the child is irritable, complains of thirst, is apathetic 
and sleepy, or at night may be delirious. The voice is usually 
changed, so that it appears muffled, and the child, if old enough, 
may complain of pain or burning in the throat. 

During the course of the first day or the first half of the second 
day of the disease the characteristic eruption generally appears, 
beginning first upon the neck and upper portions of the trunk and 
sometimes in the gluteal region, and then spreading rapidly (within 
one or two days) until the face, the whole of the trunk, and the ex- 
tremities are involved. 

A peculiarity of the eruption upon the face is that it seems to 
spare the region about the lips and nose, and sometimes of the chin, 
and this results in a marked contrast between these parts and the 
rest of the face. Such a contrast may be of considerable value in 
differential diagnosis, for in measles and rubella the parts about 
the nose, chin, and lips, are usually the first affected by the erup- 
tion. 

The eruption of scarlet fever has these peculiarities : (a) At the 
very beginning it consists of small points which are definitely sep- 
arated from each other, although they are thickly crowded ; (6) in 
the course of a very few hours these coalesce, forming a uniform 
red eruption ; (c) the spots or points are not located upon normal 
skin, but upon a surface which is at first a delicate red or pale pink, 
but which later assumes a scarlet appearance, from which the dis- 
ease derives its name. 

It usually requires more or less close observation to distinguish 
the distinct red points, for at a short distance the appearance seems 
to be one of uniform redness. The increasing redness is progres- 
sive, and while at first the skin feels smooth, as the redness becomes 
more and more pronounced the skin assumes an uneven and coarse 
feeling. Usually in the inguinal region, upon the buttocks, the 
inner surface of the thighs, at the elbow-joint and knee- joint, and 
the axilla, the eruption is more intense than elsewhere, and may 
be so pronounced as to give a bluish-red color to those parts. 

In some instances there may appear vesicles which are very 
small and filled with a transparent fluid (which later on becomes 
more or less opaque), and these dry within a few days and form 
32 



49 8 



THE ACUTE INFECTIOUS EXANTHEMATA 



scales. The favorite situation of such an eruption is upon the ab- 
domen and chest, but it may affect the back, the hands, or the feet. 
It is characterized by the name scarlatina miliaris. 

When the scarlet fever eruption is fully developed, the drawing 
of a sharp object (as the finger-nail) over the skin will result in the 
persistence of a white streak for some considerable time afterward. 
The eruption remains at its height of development for about 
twelve hours or a little longer, and then fades, so that it disappears 
by the end of the first week or the beginning of the second week. 
Desquamation is evidenced even before the fading of the eruption 
is complete, and may continue for several weeks, occurring in some 







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Fig-. 154. — Pulse ( ) and temperature ( ) of a simple uncomplicated scarlet fever. 

The acme in this case was reached somewhat late ; the defervescence is rather marked. 



situations as small flakes, and in others the skin is thrown off in 
large casts. 

The temperature keeps close pace with the eruption, so that 
upon the third day the acme is usually reached, and then with the 
decline of the rash there occurs a gradual decline in the tempera- 
ture. While there is a variation between the morning and even- 
ing temperature in the decline of the fever, if a previous morning 
or evening temperature is at any time exceeded, the cause should 
be sought for; an uncomplicated defervescence never shows such 
a rise. 

The pulse is out of all proportion to the height of the tempera- 
ture, being very rapid. This is irrespective of whether the case 
is severe or mild, and it is not unusual to find in a child of five with 
a temperature of 103 F. per rectum a pulse-rate of 160 to 190 per 



SCARLET FEVER 



499 



minute. It is a peculiar fact that even with much higher temper- 
atures the pulse-rate does not proportionately increase, although 
it still remains proportionately high. 

With the progression of the eruption to its full development the 
other symptoms, like the temperature, usually keep pace, so that 
we observe an increase in the soreness in the throat, an intensifi- 
cation of the redness and swelling, but the tongue loses its white 
coating and is denuded of its superficial layer, so that it appears 
red and smooth, with the papillae very prominent above the sur- 
face (the so-called strawberry tongue). The improvement comes 
with the subsidence of the eruption and is progressive with it. 







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Fig. 155. — Pulse ( ) and temperature ( ) of an uncomplicated scarlet fever. The 

acme in this case was reached early (on the second day) and the defervescence was somewhat 
slow and gradual. 



The glands at the angle of the lower jaw enlarge and become some- 
times quite painful, and this enlargement may persist for a short 
time after the disappearance of the eruption. Toward the middle 
of the second week the symptoms have probably all disappeared 
with the exception of the desquamation, and convalescence is 
rapid. 

Deviations from the Usual Course of Scarlet Fever. — The 
disease may be very mild, and in such cases the symptoms are but 
slightly developed, so that while vomiting is usually present even 
in mild cases, the angina and fever are not marked. The fever 
may be very transient or in some instances entirely absent. The 
eruption may exist in areas and remain pale in color, and nun- show 
a tendency to disappear quickly or remain several days in the ori- 
ginal condition. 



500 THE ACUTE INFECTIOUS EXANTHEMATA 

Now, there may be further anomalies in the course, in that one 
or more of the symptoms may be severe and the others all mild. 
This is sometimes observed in older children who have all the symp- 
toms well marked (the throat especially), but with no eruption. 

The symptoms in still other cases may be very pronounced, and 
the malignancy of the disease evidenced by the high temperature, 
the rapid failure of the heart, and the marked involvement of the 
nervous system. Death may ensue in such cases within a few 
hours, but usually the termination is delayed until the third or 
fourth day. The temperature may reach 106 to 108 F. within 
a few hours after the initial vomiting, and consciousness is lost 
early or at least is much blunted. The rash usually is slow of de- 
velopment. At times the onset is about the same as in a mod- 
erate case, and then, after the first twenty-four hours have passed, 
the disease takes on the severe form. In still other cases, while 
all symptoms are severe, the throat involvement supersedes all in 
severity. 

Sometimes there is a deviation on the part of the eruption, and 
some of these have already been referred to. It may at times hap- 
pen that upon the third or the fourth day nodules and papules of 
a deeply colored hue are observed distributed through a slightly 
uneven but not markedly raised eruption. Such is seen in the 
severe cases at times. 

Complications which Markedly Modify the Affection. — 
Scarlatinal Synovitis. — This usually occurs after the fourth day, 
or not later than the tenth, and the large as well as the small joints 
may become affected, although the wrist, the knee, and the ankle 
are most commonly affected. The local signs are very much the 
same as those of an acute attack of rheumatism, or there may be 
no swelling or redness of the joints, but intense pain upon motion. 
Such a complication is of short duration, persisting only for from 
three to five days. 

Scarlatinal Nephritis. — Practically all the severe cases of scar- 
let fever are accompanied by more or less albuminuria, and in most 
instances this is a so-called ordinary febrile albuminuria. But 
in a proportion of the cases (about 1 5 per cent.) nephritis occurs as a 
complication. If the case is septic or the angina severe, then the 
usual form of kidney involvement is acute degenerative nephri- 



SCARLET FEVER 50I 

tis (see page 298), and occurs at the acme of the fever. But the 
lesion which is most characteristic is that which occurs usually dur- 
ing the third week of the disease, and is commonly spoken of as post- 
scarlatinal nephritis (see "Acute Diffuse Nephritis" on page 298). 

Otitis. — This is such a frequent complication that its occurrence 
in a doubtful case has some diagnostic significance. It is especially 
apt to occur in infants, and more often during cold weather. 
While both ears are usually affected, they are involved at different 
times, and the usual time for the first symptoms is during the begin- 
ning of the second week of the disease. Persistent unrest and fever, 
marked anorexia, and diarrheal disturbances should at once arouse 
suspicion of this complication. Even with a perforation and good 
flow of pus, and with no detectable swelling over the mastoid, the 
fever may keep up, and indicates infection of the mastoid cells. 

The foregoing are not the only deviations and complications ; the 
disease may be complicated by one of the other infectious diseases 
(particularly diphtheria), by erysipelas, typhoid fever, or, in fact, 
most any disease of childhood. 

The diagnosis of scarlet fever would of tener be made if one were 
on the lookout for it, and especially if every child who was taken 
suddenly ill with high temperature, vomiting, and sore throat was 
looked upon as a suspect. Of course, the disease cannot be posi- 
tively diagnosed until the occurrence of the characteristic erup- 
tion, but suspicion may be aroused by certain symptoms and the 
case isolated early. The inconvenience of a needless isolation does 
not outweigh the advantage of isolation, if the case turns out to be 
scarlet fever. At the onset tonsillitis may readily be mistaken 
for the severer disease, but in the former the pulse-rate is propor- 
tionate with the rise of temperature and the congestion in the 
throat is not so sharply defined. In such cases the history of ex- 
posure to scarlet fever is of immense value, and the history of pre- 
vious attacks of tonsillitis may prove of service in distinguishing 
these cases. 

There are some cases in which the virulence of the disease seems 
to be spent upon the throat, and early in the attack the throat 
symptoms are severe, so that it may be difficult to distinguish such 
cases from diphtheria. As the eruption is usually delayed in its 
appearance and not generally characteristic in such cases, much 



502 THE ACUTE INFECTIOUS EXANTHEMATA 

dependence for an early diagnosis must be placed upon the history 
of an epidemic and of exposure to the same. 

This, of course, would be further substantiated by a bacterio- 
logic examination. As to the symptoms present, a sudden onset 
with vomiting, high temperature, and very active inflammation in 
the pharynx would indicate scarlet fever. The disproportion 
between pulse and temperature would also have a similar indica- 
tion. 

By far the greater number of mistakes come from a misinterpre- 
tation of the eruption. In the well-developed cases the character 
of the eruption is sufficient, when associated with other symptoms 
of the disease, to make the diagnosis plain. But, unfortunately, 
there are other acute diseases which exhibit quite early in their 
course an eruption which may simulate some one of the forms of 
the scarlet fever eruption. Such may be the case in an acute lobar 
pneumonia, and it may be necessary to wait until the development 
of the physical signs of the pneumonia before the differentiation is 
positive. The most likely error, however, is in diagnosing the case 
as one of lobar pneumonia with erythema, when it is really a scarlet 
fever, and such errors usually are made because little or no atten- 
tion is paid to the examination of the throat and to the history of 
exposure. 

Then, again, there are many eruptions of the skin (toxic exan- 
themata) which are a source of much confusion, even to the ex- 
perienced. It is, therefore, not the part of wisdom to make a pos- 
itive diagnosis from the eruption alone, but to consider carefully 
every associated symptom and the history. Occasionally one may 
observe skin eruptions which are of a scarlet color and are produced 
by quinin or antipyrin or belladonna. In such instances the 
injection of the deep layers of the skin and the uneven feel which 
are so characteristic of scarlet fever are absent. The eruption 
which may be associated with the injection of animal serums into 
the blood (particularly the antitoxin for diphtheria) often causes 
confusion, because at times it appears with considerable elevation 
of the temperature, cephalalgia, and vomiting (and in rarer in- 
stances with congested throat), so that the simulation to a com- 
mencing scarlet fever may be marked. Every possible fact must 
be weighed in these cases, and even then it is sometimes necessary 



SCARLET FEVER 503 

to await further development before an opinion may be reasonably 
given. 

In cases of scarlet fever in which the eruption remains undevel- 
oped, existing as a pale and indistinct macular rash, the danger of 
error is great. Such an eruption may be due to several conditions ; 
it may be scarlet fever, it may be the scarlatinal form of rubella, 
or it may be due to serum injection. The history of serum injec- 
tion and the absence of exposure to scarlet fever would naturally 
help in the differentiation of a serum rash. 

Under ordinary conditions rubella occurs with little or no febrile 
disturbance, but, on the other hand, one observes at times cases 
of scarlet fever with little or no temperature, so that that point of 
differentiation is more apparent than real. In rubella the finely 
punctiform eruption which is characteristic of scarlet fever is never 
observed, and if a careful search is made of the whole body, especi- 
ally at the joints, one rarely ever fails in finding at least small 
patches of eruption which are characteristic in appearance. One 
must, however, examine carefully the mouth and pharynx, for 
strongly suggestive of scarlet fever are the strawberry tongue and 
sharply defined congestion of the velum of the palate, the palatine 
arches, the uvula, and tonsils. Then, again, with even a well- dis- 
tributed eruption, rubella has few or no constitutional symptoms, 
while with a similarly distributed rash scarlet fever would exhibit 
many and pronounced symptoms. 

The liability of diagnosing a case of scarlet fever as a case of 
rubeola may come from the eruption departing from its usual ap- 
pearance and exhibiting a coarse macular and partly papular 
appearance upon some areas of the skin. The differentiation is 
based upon the vastly different modes of onset, the time of the ap- 
pearance of the rash, and its course and distribution. The changes 
in the mucous membranes of the mouth and pharynx are also usu- 
ally sufficient to make the distinction clear. 

During infancy especially, but by no means confined to that 
period of life, there are observed a large variety of rashes which 
markedly simulate the eruption of scarlet fever. Most of these 
arise under the influence of digestive disturbances and are of brief 
duration. 

Peculiarly deceptive is that mild form of acute exfoliative dor- 



504 THE ACUTE INFECTIOUS EXANTHEMATA 

matitis known as scarlatiniform erythema, because of its sudden 
onset with fever and an eruption which spreads quickly over the 
whole body, persisting at times for three or four days. Desqua- 
mation follows to add to the deception. As relapses are common, 
the history of previous attacks are of immense value, but when the 
attack is the first or second one, then the diagnosis may be im- 
possible for a day or two. 

Much dependence must be placed upon the conditions which are 
found in the oral cavity and the pharynx, which are somewhat 
characteristic in scarlet fever and absent in erythema. But the 
erythema may accompany diphtheria (this is not an uncommon 
happening) , and in such cases I know of no way of making a posi- 
tive diagnosis, except by waiting and watching the further develop- 
ment of the affections, or to rely upon the findings of a bacteriologic 
examination. 

The general statement may be made that in erythema scarla- 
tiniforme throat symptoms are absent, or amount only to very 
slight congestion without swelling ; the rash is out of all proportion 
to the constitutional symptoms, and there is a tendency to rapid 
clearing of one area with as rapid involvement of another. When 
the case is seen late and desquamation is present, the differential 
points are as follows : in scarlet fever desquamation usually occurs 
first upon the face and on the fourth to sixth days ; next upon the 
neck and chest, from the sixth to eighth day ; then upon the hands, 
from the twelfth to fourteenth day, and lastly upon the feet about 
the third week. In the unmentioned parts there is no particular 
constancy as to the time in which desquamation occurs. Now, 
in all other rashes which in any way resemble the scarlet fever erup- 
tion, and which are not due to contagious disease, the desquama- 
tion almost invariably starts upon the hands and the feet, and 
usually some earlier than the fourth day. 

Peculiarly indicative of scarlet fever desquamation is the scaling 
which occurs just beneath the free border of the nails and extends 
down the finger. One must always bear in mind that not every 
diffuse rash which ends in desquamation is scarlet fever; other 
toxins are capable of causing the same thing. 



VARIOLA 505 

VARIOLA 

Fortunately there is not now an abundant opportunity to ob- 
serve this disease ; still, the laxity and variety of the laws relative 
to vaccination in the United States allow of more chance to observe 
the disease than is necessary. In a consideration of the protection 
which is afforded by vaccination, little reliance can be placed upon 
the statements of parents that the operation was recently per- 
formed, but this needs corroboration by the exhibition of a proper 
scar. Time and time again children are vaccinated and a certifi- 
cate is given of that fact, without any effort being made to deter- 
mine later on if the procedure was successful or not. This gives 
a sense of false security to the person ; hence the necessity of see- 
ing a good scar. 

The disease is one which is most highly contagious; one which 
affects all races and ages, but which is particularly fatal to the 
young child. The period of incubation is not marked by any ap- 
preciable symptoms, as a rule, but at times there may be very slight 
and indefinite ones, which are in no way suggestive as far as diag- 
nosis is concerned. 

The onset of the disease is very abrupt, with a decided chill in 
older children and convulsions in the younger child, and these 
have as their accompaniment a rapid rise of temperature. There 
may be vomiting at the onset also. The usual symptoms which 
accompany a high and rapid elevation of the body-temperature 
occur in variola with unusual intensity, and this is characteristi- 
cally true of pain in the lumbar region, which is generally quite 
excessive. 

It is not unusual for the pain to extend to the front of the body 
and to the inguinal region and for the case to be looked upon as one 
of spinal meningitis. If the child has been exposed to smallpox 
and is suddenly taken ill with a chill or convulsion, with high tem- 
perature and marked lumbar pain, the chances are in favor of 
variola; but if there has been a previous complaint made of head- 
ache, persisting for some hours or a day or two, and then a sudden 
seizure with rigors, convulsion, or explosive vomiting and great 
weakness of the limbs, the chances favor a diagnosis of meningitis- 



506 THE ACUTE INFECTIOUS EXANTHEMATA 

Much care must be observed, however, to elucidate the history of 
exposure and of protection by vaccination. 

The possibility of mistaking the disease for pneumonia at this 
time is rather small, for in that disease, while the symptoms of the 
onset may be similar in many points (sudden high temperature, 
vomiting, chill, or convulsion), the lumbar pain is absent, and the 
respirations are increased out of all proportion to the pulse (and 
there may be cough and rough respiratory murmur even at this 
early stage). 

Not uncommonly, while the fever is present, there occurs a dif- 
fuse redness of the skin, which is uniform and most noticeable upon 
the trunk. In the triangular space bounded above by a line which 
would cross the umbilicus and an apex formed by the closed thighs, 
the sides of the triangle being bounded by the inguinal regions, 
there is a still more intense reddening (occasionally with purpuric 
areas). 

There may occasionally be erythematous patches in various 
portions of the body. The possibility of mistaking this prodromal 
eruption for scarlet fever rash is small, although with a hasty ex- 
amination such an error might occur. At this time, if there is 
anything which compels the child to breathe through the mouth, 
then there is considerable pain in the throat, which is occasioned 
by the intense dryness of the mucous membranes. 

The phenomena of the stage of invasion last for two or occasion- 
ally for three days, when, with a marked remission of the fever, a 
general improvement of all the symptoms occurs, and at the same 
time the characteristic eruption makes its appearance upon the 
skin. The face is the first portion affected, but during the succeed- 
ing forty-eight hours the eruption spreads over the trunk and the 
limbs. Usually the eruption is developed with an associated red- 
ness of the face which may be more or less diffuse. 

The first appearance is somewhat like that caused by the bite 
of a flea, for there are sharply defined, circumscribed, red nodules 
which are first observed upon the face (and occasionally upon the 
forehead and scalp there may be noted hard nodules which feel 
like shot, but upon which no redness is seen), while at the same 
time, upon the dorsal surface of the hand, upon the forearms, and 
sometimes upon the trunk and neck, similar hard nodules are noted, 



VARIOLA 507 

but with intense redness. These develop into small papules within 
two to three days, and after twenty-four or forty-eight hours more 
they become vesicles which at first contain clear fluid, which rapidly 
becomes turbid. 

It is usually on the seventh day of the disease that the typical 
vesicle is fully formed. This is a flat vesicle which shows in its 
center a slight depression (umbilication). Upon the eighth or 
ninth day, as a rule, the vesicle has developed into a pustule. 
About the eleventh or twelfth day the pustule begins to dry and 
there is an associated itching with the process. The pustules 
partly rupture (may be occasioned by scratching or rubbing) , and 
as the contents exude they dry, forming crusts. In those pustules 
which are not ruptured the contents dry slowly with a decrease in 
the surrounding hyperemia of the skin. The crusts are thrown 
off toward the end of the third week of the disease, and if the pus- 
tules have been located deeply in the true skin, pitting occurs. 

Now, to return to the constitutional symptoms: the fever, 
which remitted when the eruption first appeared, reappears with 
the further development of the rash, and may assume quite as 
high a degree as the initial fever. With the drying up of the pus- 
tules the fever subsides slowly by lysis. 

About this period various and rather severe nervous phenomena 
are very apt to be present, on account of the fever, the pain which 
is caused by the development of the pustules upon an unyielding 
skin (as upon the soles and palms), and from the inflammation of 
the skin and also from the toxic effect of the numerous foci of pus. 
Focal affection of the brain and spinal cord or of the peripheral 
nerves usually adds to the difficulty, and it is easy to understand 
that with a disease with such innumerable pus foci the most varied 
metastatic inflammations may arise. 

There are three almost universally recognized varieties of the 
disease : 

(a) Discrete variola, in which there are few pocks and these are 
separated by intervening perfectly normal skin. 

(b) Confluent variola, in which the pocks are closely crowded, 
so that they coalesce, and the distribution is pretty general over 
the whole of the body. In this form the symptoms are usually 



508 THE ACUTE INFECTIOUS EXANTHEMATA 

all intensified and the eruption may appear earlier than the usual 
time. 

(c) Malignant variola, in which blood is exuded into the skin 
and mucous membranes, so that one may observe petechiae and 
ecchymoses in the skin and more or less profuse hemorrhages may 
occur from any of the mucous surfaces. The eruption in such 
cases is usually much delayed or may be entirely absent. 

When the eruption of variola is well developed, there is usually 
no difficulty in making a diagnosis, but the highly contagious na- 
ture of the disease and the tenacity of the contagious principle 
demand that the earliest possible diagnosis be made. 

The greatest difficulty will naturally be offered by the modified 
form of the disease — varioloid. Varioloid occurs in a person who 
is practially protected by a previous vaccination, or who offers 
some degree of immunity from other causes. Besides its mildness, 
which is its marked characteristic, it differs from variola in that 
the development of the symptoms is very irregular. 

In children the initial symptoms are usually just as severe as in 
variola and erythematous rashes are commoner, but the manner 
of the distribution of the eruption may be totally different (occur- 
ring at times upon the face last). Generally when the eruption 
reaches the vesicular stage the further development is arrested 
and the vesicles dry up about the sixth day. Pustules may pos- 
sibly form, but they do not fully develop. There is generally little 
or no secondary elevation of temperature, and the eruption is dis- 
crete. A safe rule is to always suspect the severer form until it 
can be clearly and undoubtedly shown that the modified form is. 
present. 

During the papular stage of the eruption, as long as the eruption 
remains maculopapular and of a dusky red color upon the face, 
it may readily be mistaken for rubeola. This error, however, is 
much more liable to occur in adults than in children, on account 
of the delicacy of the skin during childhood allowing a freer de- 
velopment. Such errors might be more easily avoided if one 
recalled that the eruption of measles occurs later than does that of 
variola, and that the catarrhal symptoms which are present in 
rubeola are usually well marked and precede the eruption by 
several days (usually three or four). While the absence of Kop- 



VARICELLA 509 

lik's spots would be of no deciding value, their presence would at 
once determine the presence of rubeola. It might be helpful in 
some cases to make an examination of the urine, and the presence 
of the diazo-reaction at the time of the appearance of the erup- 
tion would favor the diagnosis of rubeola. 

It may occur at times that the greatest uncertainty obtains in 
regard to the preceding history of the case at the time of the first 
appearance of the eruption, and in that case delay is necessary be- 
fore an opinion may be expressed as to anything positive. If within 
twenty-four hours the spots have not enlarged, but have simply 
increased in number and assumed a bluish-red color and the fever 
continues to rise, then the diagnosis of rubeola may be made with- 
out further delay. Urticaria may occur in a papular form which 
may closely simulate the eruption of smallpox, but it is always 
accompanied by more or less intense itching, and the whole history 
is totally different. 

The differentiation from varicella will be found under the section 
dealing with that disease (see page 511). 

Just a word in regard to abortive variola : it differs in no way at 
first from the regular form of the disease, but all symptoms are 
limited to the prodromal period. The diagnosis must be made 
upon the appearance of the prodromal rashes in the typical situa- 
tions and upon etiologic factors. There is no eruption. 



VARICELLA 

This acute infectious and epidemic disease is evidenced by mild 
constitutional symptoms and a vesicular exanthem which occurs 
in successive crops. Usually the exanthem is the first thing no- 
ticed, but there may be at times prodromes which are in no way 
suggestive (anorexia, slight elevation of temperature, restlessness, 
cephalalgia, etc.). 

In a very large proportion of the cases the eruption is the first 
symptom, and appears upon the face and then spreads to the scalp, 
the trunk, and finally the extremities, or may appear primarily 
upon the back and shoulders. But whatever the situation of the 
first appearance, the whole body is finally spotted with the erup- 
tion, which shows a marked tendency, which amounts to a charac- 



5IO THE ACUTE INFECTIOUS EXANTHEMATA 

teristic, to become most noticeable upon the trunk and upon the 
upper portions rather than upon the lower. 

An erythematous rash may appear before the eruption, and 
when this occurs, the peripheral lymph-glands are generally 
somewhat tender and may be swollen also. The disease is very 
benign and occurs in nearly every instance before the age of seven, 
and after ten years of age it is rather an unusual occurrence. 

The eruption is of small, red, scattered, flat, circular or ovoid 
papules. These come out in successive crops. The papule rap- 
idly develops into a vesicle, the evolution occupying about twenty- 
four hours or a much shorter period. At first the vesicle is gener- 
ally hemispheric and superficially located, with limpid contents, 
so that commonly the appearance is as though a drop of some faint 
yellow fluid had been placed upon the skin. 

This appearance does not last long, for within a few hours they 
take on a milky color and finally become seropurulent. Then 
another change occurs, for desiccation takes place, with the for- 
mation of flat yellowish-brown crusts which are firmly adherent, 
but which separate in about one week without scarring. Rupture 
of the A^esicles does not occur spontaneously, but from rubbing or 
scratching, and under such conditions slight scars may result. The 
vesicle is not surrounded by any area of hyperemia or infiltration 
except in rare instances. 

The foregoing description applies only to the first few crops of 
the exanthem, for later in the affection the papules do not, as a 
rule, develop into vesicles, but dry up and undergo complete 
absorption within about twenty-four hours. These later papules 
are also much less numerous than the earlier crops. 

The rapid changes which occur in the pock, and the fact that 
they appear in successive crops, give us, by the fourth or fifth day 
of the affection, the characteristic appearance of an eruption in all 
stages of evolution and involution. The number of the pocks 
may vary from a very few to several hundreds, but even when 
thickly crowded, it requires very careful search to detect any con- 
fluence. Umbilication is never seen except as desiccation takes 
place, and then occasionally a central depression is observed in 
the crust. 

When the affection is mild, no fever is present, but in severe at- 



VARICELLA 5 1 1 

tacks there may be a slight elevation before the appearance of the 
rash ; but if not present at the time, it occurs coincident ally with 
the eruption. The temperature may remain elevated for two or 
three days, or more rarely it persists for a week, but in any event 
conforms to no regular type. 

In rare cases the vesicles may contain some blood and be asso- 
ciated with slight bleeding from the mucous surfaces. Still rarer 
are the instances in which bullae are developed or gangrene occurs. 

The diagnosis is very easy if the case is seen from the beginning, 
but such is not usually the fact. Then the diagnosis has to take 
into consideration a discrimination between varicella and variola, 
or between the former disease and impetigo contagiosa. 

In regard to the differentiation from variola, we inquire at once 
into the vaccinal history. Regardless of such, we observe that 
the initial symptoms are usually severe in smallpox and are present 
for from two to three days before the eruption, and that at the 
time of the appearance of the eruption the fever suddenly sub- 
sides. The onset of variola is abrupt usually, with high tempera- 
ture, headache, and, what is most characteristic, with severe lum- 
bar pain, which is out of all proportion to the constitutional symp- 
toms present. But the onset of variola may be accompanied by 
very mild symptoms and the onset of varicella by very severe ones ; 
and these unusual cases are the puzzling ones. Then the points 
to be considered are that in varicella the fever and the eruption 
appear together (or if fever precedes the eruption, it is mild and 
becomes more severe at the time of the appearance of the rash), 
while in variola there is a marked remission of the fever at the time 
of the appearance of the eruption. 

The eruption of variola is most marked on the face, hands, and 
feet ; in varicella, upon the trunk and back, and particularly the 
upper portions of the same. Further than this, in variola the 
eruption has a fine shotty feel, and the development is slow and 
by progressive stages of papule, vesicle, pustule, and crusts, while 
in varicella the rash is vesicular in a very short time, with a soft 
feel and easy rupture. If the varicella vesicle be artificially rup- 
tured, the contents are readily discharged; if a similar process is 
attempted with the vesicle of variola, the contents will not exude. 



512 THE ACUTE INFECTIOUS EXANTHEMATA 

except with difficulty. The varicella eruption is not primarily 
umbilicated, but in variola it is. 

When the case is seen late, there may be a marked resemblance 
to impetigo contagiosa, for there is now desiccation of the vesicles. 
The distinguishing features are that in impetigo contagiosa the 
vesicles formed are thin-roofed and flaccid, and these or the blebs 
become pustular, rupture, and form superficial crusts. The face 
is usually the only part of the body affected, or from this there may 
be distinctly traced an eruption which follows closely inoculation 
by the fingers (through scratching). There are no general symp- 
toms and a rather chronic course is the rule. 



DIPHTHERIA 

This highly contagious disease is common, because of its being 
directly transmissible from one child to another, or indirectly to 
the child through the agency of a third person and infected fomites. 
While there is no exemption which is offered by age, still the disease 
occurs with greatest frequency between the ages of two and six. 

There is no well-marked difference in its occurrence in the differ- 
ent seasons, although the catarrhal conditions which are usually 
present in the fall and winter must predispose to its occurrence. 
Whether the child be under the best hygienic conditions or not 
does not make much difference ; all are attacked with equal vir- 
ulence. 

It is a constant revelation to one who sees many cases of diphthe- 
ria that the disease naturally divides itself into two classes: the 
mild form, in which the area of the disease is limited and the toxins 
quite harmless, and the severe form, in which local limitation 
does not obtain and the intoxication is extreme. 

It might be presumed that in a disease which is so characteris- 
tically developed, with local symptoms, the diagnosis would be 
very simple, and up to a certain point such is the case. But even 
with the wide experience which is of such value in the recognition 
of the disease, there occur frequently cases in which one cannot 
be positive of the diagnosis without a confirmatory culture. 

The prodromes are so uncertain that there is rarely a recognition 
of them. There may be evidences of a slight chilliness and 
malaise, and perhaps some congestion of the fauces. 

If the case be one of the mildest type, there may be evidences of 
a moderate catarrhal inflammation of the fauces, of the pharynx, 
or of the nose, associated with some tenderness and slight swelling 
of the cervical glands, and nothing more of a local nature. If the 
nose is involved, there is usually the discharge of a blood-streaked, 
irritating, and thin secretion. Constitutional symptoms are usu- 
ally mild, the only one of any import being a slight elevation of the 
temperature. 

33 513 



5H 



DIPHTHERIA 



Such mild attacks are dangerous in several ways : first, they are 
usually not recognized at once; second, they infect others; and, 
third, they may be followed by sudden and severe laryngeal involve- 
ment. If it became a routine practice to examine the throats of 
all sick children, as it should be, many of these cases would not be 
overlooked, for the detection of the inflammation would often lead 
one to adopt the only positive means of diagnosing these cases — 
the bacteriologic examination. A wise plan is to consider all acute 
inflammations, whether nasal, faucial, pharyngeal, or laryngeal, 
as suspicious until proved otherwise by the clinical course or by 
bacteriologic examination, and this applies with particular force 
in the presence of a known epidemic. 

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Fig. 156.— Chart of the temperature ( ) and pulse ( ) in diphtheria. Child four and 

one-half years old. 



very mild type, may occur with some soreness of the throat which 
is accompanied with mild fever and a deposit (of a white or gray 
color) upon one or both tonsils. It is usually the low temperature 
(ioo° to 102 F.) and the persistence of the deposit (for from four 
to ten days) which leads one to suspect diphtheria, for otherwise 
the disease seems a trivial affair, and the child usually persists in 
being about as usual. 

The diagnosis is usually made of follicular tonsillitis, and there 
is nothing but a culture which will at times positively make the 
distinction. Unless the symptoms are so developed that doubt 
is practically removed beyond all question, tonsillitis should be 
looked upon with doubt. 



DIPHTHERIA 515 

When tonsillitis is present, there is almost always a marked 
hyperemia and usually a high temperature — much higher than 
seems to be expected with such local symptoms. It is generally 
easy to wipe away, without causing bleeding, any of the spots on 
the tonsils which are the result of a simple inflammation. 

In the severe cases the onset may be very insidious or may occur 
abruptly, with some soreness of the throat and slight fever, which 
daily increases, or with vomiting, chilliness, marked malaise, ano- 
rexia, or headache. These may be associated with some tenderness 
or slight swelling of the cervical glands, which latter at times may 
be the first thing which is noticed. 

Whether the attack be one of the milder forms or of the severe 
type, we have seen that there is little about the onset which is at 
all suggestive, and yet there is some value in the early symptoms 
when taken collectively. 

Naturally, the first matter that one would attend to would be the 
question as to the prevalence of any epidemic. This would natur- 
ally lead to a study of the child's surroundings: Does he go to 
school and so come in contact with many children? Has he been 
in an infected locality? Are there other cases near by? What is 
his age? (If over twelve years of age, the chances of his having 
diphtheria are much less.) Has he ever had attacks of tonsillitis? 
(There is a distinct value in a clear history of repeated attacks of 
such, for it reveals a tendency and suggests further examination 
for rheumatic affection of the heart.) 

There is one thing that is usually marked about the onset of 
diphtheria, and that is that the temperature is low (that is, taken 
altogether, it is lower than in other inflammations of the throat). 
Sudden development is the exception and not the rule in diphthe- 
ria. If during the onset there be a nasal discharge present which 
is irritating and blood-streaked, or if the cervical glands are ten- 
der, even without being enlarged, it is strongly suggestive of diph- 
theria. 

For an early diagnosis dependence must be placed more upon the 
result which is obtained from a culture and upon the local signs 
than upon the general symptoms. The value of a culture must 
not be overestimated, however, for many times the result will be 
negative on one examination and positive on the subsequent ones. 



516 DIPHTHERIA 

On the other hand, a culture may be positive, and yet the child be 
free from diphtheria. What, then, is our position in the matter? 
Simply this : that the bacteriologic findings must be supplemental 
to the clinical history: the two must be considered together. 

When we come to consider the local conditions, we find that the 
characteristic membrane usually appears at first as a thin gray 
film which gradually but progressively becomes more dense and 
perhaps whiter in color. As the membrane ages, it becomes more 
gray, brown, or even black. The most marked feature is its pro- 
gressive spread from a small patch to a much larger one. The 
usual situation is at first upon the tonsils, although one is commonly 
affected for a day or more before its fellow, and occasionally it is 
confined to the one tonsil. 

The membrane is not readily removed, and when any force is 
used, bleeding is the usual result. The fact that a membrane is 
apparently present is not of as much importance as the fact that 
it spreads, and particularly where it spreads to. If it spreads be- 
yond the tonsil, it may be regarded, with almost absolute certainty, 
as diphtheritic. Or, if limited to the tonsils, but with little or no 
surrounding inflammation, it is most likely diphtheria. 

If upon an examination of the throat we find that there is an 
intense degree of inflammation, and that there is some edema of 
the uvula and faucial pillars, or that the membrane which is pres- 
ent is easily removed or broken, we are quite safe in assuming 
that we are not dealing with diphtheria (unless it be complicated 
with some other throat inflammation). 

There are exceptions to all rules, and so we find that in a strep- 
tococcus infection of the pharynx and tonsil, such as is common 
during the early course of scarlet fever, of rubeola, and some of the 
other infectious diseases of children, the membrane which is formed 
is very adherent and quite similar to that of diphtheria. There is 
one marked difference, however, in the associated symptoms: in 
streptococcus infection the elevation of the temperature is marked 
(105 to 106 F.), while in diphtheria low temperature obtains. If 
such a condition of the throat should occur late in the course of 
these diseases (as after four or five days' illness), then the proba- 
bility of its being an added infection (diphtheria) is great. 

Outside of the local symptoms we have constitutional ones, 



DIPHTHERIA 517 

which are dependent upon the absorption of the toxins and the 
resulting effect upon the functions of the various organs of the body. 
Therefore it is seen that in mild attacks the constitutional symp- 
toms are so slight that one may readily be deceived in regard to 
the danger of the infection. 

In the pharyngeal type there is usually a day or so of listlessness, 
anorexia, and perhaps some vomiting. The temperature is slightly 
elevated, the pulse accelerated, and the urine scanty and high- 
colored, and usually with some albumin. If the child be old 
enough to complain, it does so of headache and pain in the limbs 
and back. If a rash appears upon the skin (as is not unusual), it 
may resemble somewhat that of scarlet fever or rubeola, and these 
diseases may be suspected. The prodromes of rubeola are usually 
sufficient to stamp this disease at once, but when we attempt to 
differentiate scarlet fever, the difficulty is greater. However, it 
is in just such cases that the value of a bacteriologic examination 
is marked. If the pharyngeal type be unusually severe, there is 
added a considerable degree of prostration, with the temperature 
remaining about the same, but the pulse more rapid and weak. 
The skin may become cyanotic, the child semi-comatose, and the 
urine suppressed. There is generally a foul odor to the breath. 

In the nasal type the symptoms are about the same as in the 
foregoing type, with the added ones of epistaxis, or the discharge 
of blood-streaked secretion which excoriates the skin. Mouth- 
breathing is common, and the temperature is usually more elevated 
and the glands in the neck markedly swollen. These symptoms 
are added to those of the pharyngeal type because it is common 
for both to exist together, and unusual for them not to. 

It will be well to consider the symptoms which accompany the 
laryngeal type more in detail, for the experienced physician will 
always view with much alarm the occurrence of any symptoms 
which denote a laryngeal involvement or which evidence its in- 
crease when already present. The most characteristic symptom 
of laryngeal involvement is thickness or hoarseness of the voice or 
cry, with the probable associated symptoms of a dry, harsh, and 
barking cough and stenotic breathing. 

In nearly all instances the involvement of the larynx occurs 
while the membranes are still present in the pharynx, but some- 



518 DIPHTHERIA 

times it is not evidenced until the membranes have entirely disap- 
peared. In other instances it is secondary to a nasal diphtheria, 
in which there may have been little or no involvement of the phar- 
ynx. 

Of course, with such a severe disease we occasionally notice that 
a catarrhal laryngitis occurs, but the moment a rough, harsh cough 
occurs with hoarseness of the cry or voice, suspicion should be at 
once aroused that the larynx is affected and an exudation forming 
there. Reflex cough occurs in the pharyngeal type without any 
laryngeal involvement, but in that condition the cough is clear, 
distinct, and hacking, and the voice is not muffled or hoarse. It 
is frequently noted that the cough and hoarseness are improved 
during the daytime and become more marked at night, and such 
an occurrence in itself should arouse suspicion. 

Dyspnea is very real, so that the child has an anxious expression, 
the eyes are generally widely opened, the alse nasi dilating with 
each respiration, and with each of the more or less long and hissing 
inspirations there is a very evident participation of all or most of 
the accessory respiratory muscles in the act of respiration. Unless 
relief is quickly obtained, cyanosis soon comes on. About this 
time convulsions are common, and the little one may at any time 
sink into a deep coma, with the cyanosis marked, the pulse feeble 
and very rapid, the respiration gasping, and the whole picture one 
of intense distress and of impending death. 

When the diagnosis of the disease has been made and its extent 
determined, there is still much left for the diagnostician to con- 
sider. 

There are many important sequels which must be recognized 
early, and perhaps the chief of these are the cardiac symptoms. 
We are often at a loss to explain the loss in the action of the heart, 
and this is particularly true when death occurs rapidly, while in 
the more protracted instances there are well-marked cardiac 
changes, which are easily recognized. It is most important to 
treat the cardiac condition before it occurs and there are some 
symptoms which prophesy its onset. 

Vomiting occurring during the course of diphtheria, unless it 
can be clearly explained as due to some other cause, ought to 
place us in a position of great suspicion, at least. The same may 



DIPHTHERIA 



519 



be said of a persistent coldness of the limbs. When either of 
these are present, no matter what the apparent condition of the 
heart muscles may be, cardiac involvement should be looked for. 

It is not always necessary to wait until we obtain the more 
positive signs of arrhythmia or increasing dullness of the heart- 
sounds. Sometimes, when an examination is made, it is noted 
that the cardiac impulse is weakened, and upon auscultation there 
are heard what seem to be three heart-beats, with the middle one 
particularly accentuated. When the heart is involved, death 
may take place in. one of two ways: suddenly and almost without 
warning during an attack of vomiting, or slowly with varying 
collapse-like attacks. 

It is a well-recognized fact that a severe attack of diphtheria 







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Fig. 157. — Chart of the temperature ( ) and the pulse ( ) in diphtheria. Child 

five years old. Death occurred suddenly upon the evening of the sixth day. While the case 
was treated in expectancy of cardiac paralysis, this was not actually evidenced until the even- 
ing of the third day, when the disproportion between temperature and pulse gave the first warn- 
ing, irregularity of the pulse soon being in evidence. Death came with a mild vomiting attack. 



rarely, if ever, occurs without some pathologic involvement of the 
kidneys. Such an involvement may be shown by albuminuria, 
diminution in the amount of urine, or renal hemorrhages. Unlike 
most other renal involvements, in diphtheria, dropsy and the 
occurrence of the uremic symptom-complex are both rare. 
Acute nephritis is an occasional sequel which may not occur until 
convalescence is well established, or it may come on several weeks 
later. 

Diphtheritic paralysis is an important sequel, and divides itself 



520 DIPHTHERIA 

into two groups — the early and the late. Early paralysis occurs 
in the more severe cases, and always begins in the velum of the 
palate. It is associated with severe prostration and accompanied 
by adynamic cardiac conditions, being almost uniformly fatal. 

The late paralyses are commonly known as post-diphtheritic, 
and occur from two to five weeks after the onset of the diphtheria, 
as a rule. The palate is usually the part most affected, and the 
first symptom noted may be a nasal twang to the voice, or diffi- 
culty in swallowing, so that the child in the attempt brings through 
the nose some of the liquid which is taken. In cases in which it is 
watched for (and this is unusual in private practice, as a rule) 
the patellar reflex is absent, and this is a very early symptom. 
The development of post-diphtheritic paralysis is not regular. If 
the absence of the knee-jerk be associated with albuminuria and 
a general lassitude of the patient, and the preceding history has 
been of an attack of diphtheria (or even of severe sore throat), 
one is justified in suspecting the onset of paralysis. 

At the time that the palate is first involved (as evidenced by 
the changed voice) there is more or less tingling and weakness in 
the extremities, and particularly the legs, although it is rarely 
sufficient to cause the child to complain. The paralysis may 
involve the palate alone or extend to the musculature of the 
pharynx and larynx also. Many times the paralysis will be 
apparently limited to the throat, but a careful search will reveal 
some degree of paralysis in other parts. 

Next in frequency to the throat involvement the legs are usually 
affected, and the symptoms do not differ from those which are 
caused by multiple neuritis from other causes, except in the ab- 
sence of pain. When the legs are affected, there is usually an 
inability to use the eyes for close work also, or there may be 
strabismus. 

It must not be expected that the paralysis of the limbs will be 
complete; in nearly every instance there is simply an evidence of 
a more or less marked weakness and flabbiness. Paralysis affect- 
ing the arm is of evil import, usually predicting cardiac paralysis. 
The recovery from the paralysis is complete when it occurs. 

Respiratory paralysis may occur, and the first warning is usually 
the occurrence of dyspnea, with an empty toneless cough, the 



DIPHTHERIA 521 

attacks increasing in severity and sometimes in frequency as 
time goes on. 

It is very important to recognize the important sequels as 
early as possible; it is more important that they be anticipated 
and the treatment be such as to limit their occurrence. 



RHEUMATISM 

To make an early diagnosis of rheumatism in the child is of 
great importance. That much must be admitted, for without 
an early and positive recognition of its existence, incalculable 
damage may result to the child. The main object in the recogni- 
tion of rheumatism at an early stage is the prevention of cardio- 
vascular changes. 

In approaching the subject we must leave behind all precon- 
ceived ideas and deductions which we have acquired by our 
study of adult cases, for rheumatism in the child is markedly 
different in its clinical aspects from the similar state in the adult. 

A rheumatic arthritis per se has little to do with the cardiac 
changes which occur in the child. These little ones are injured 
while suffering from a faulty metabolism and may suffer severe 
damage to the heart without ever having had any arthritis, or, 
in fact, any of the usually recognized symptoms of rheumatism, 
except the so-called growing pains, leg cramps, iritis, myalgia, 
tonsillitis, or chorea. Arthritis, strictly speaking, is not the 
cause of the cardiovascular changes; the diathesis which causes 
the one, induces the other. 

The earliest possible recognition of the existence of rheumatism 
in the child is offered by a correct estimation of the functional 
capacity of the heart, for in no other condition is functional 
perversion so constant. Probably one of the best methods of 
testing the functional capacity of the heart is that which is known 
as Herz's arm-flexion test. The diagnostician supports the 
elbow of the patient by letting it rest upon his hand, and with the 
other hand the wrist of the child is very lightly grasped. The 
child is then told to concentrate his attention as closely as possible 
upon what he is about to do. Then he is requested to perform a 
very slow and uniform flexion of the forearm, and this is not to be 
resisted by the examiner. As little effort as possible is to be put 
into the movement. After flexion, there must be an equally slow 
and deliberate extension. 

S22 



RHEUMATISM 523 

The pulse, which should have been previously counted, is then 
immediately counted as extension is completed. Now, if the 
myocardium is not absolutely normal and sound, a very noticeable 
difference in the two takings of the pulse is observed. In abnor- 
mal conditions there will be noted a slowing of the pulse-rate, but 
an increase in the size and strength of the pulse-wave. If the 
functional capacity be normal, nothing but a slight acceleration 
is observed. 

My favorite method has always been to give the child a small 
dose of digitalis (one minim to a child of seven years) and note 
whether there is any appreciable difference in the rate or quality 
of the pulse under conditions similar to those which existed 
previous to the giving of the drug. A perfectly normal heart 
should not be affected by such a dose. 

I emphasize the importance of the cardiac changes because they 
are so frequent and so prominent. Their influence upon the 
course and the outcome of the disease is so marked that at times 
it might almost leave one in doubt as to whether or not they 
should be considered as the typical characteristics of the disease. 
As has been stated, the cardiac changes or manifestations may 
occur when articular symptoms are very mild or absent entirely. 

The most frequent form of cardiac disease is endocarditis, 
which is observed in all severe cases and in a very large proportion 
of all cases. It is not always recognized at first, so that the child 
may suffer two or more attacks of the articular symptoms before 
the cardiac condition is recognized. In many instances the cardiac 
changes are first noted and the articular symptoms follow appar- 
ently. In children who are over eight years of age there is fre- 
quently a pericarditis associated with an endocarditis ; under the 
age of eight, pericarditis is not so frequent. 

Still, it is not simply by one or two particular symptoms that 
the disease is recognized in childhood, but by the combination or 
association of a number of symptoms which may apparent ly be 
unrelated. An illness which has an abrupt onset, with slight 
fever and tenderness, but with general symptoms which are 
indefinite, is strongly suggestive of rheumatism. 

There are certain factors which are very helpful in the diagnosis, 
particularly the family history and the previous condition of the 



524 RHEUMATISM 

patient. The influence of heredity is very strong, and a child of 
rheumatic parentage is very liable to develop the disease in some 
form in the presence of very slightly active causes. If both 
parents be rheumatic, then the liability is much increased. Early 
in life boys seem to be more often affected than girls, but between 
the ages of five and ten the sexes are about equally susceptible; 
between ten and puberty, girls are most affected. 

The previous condition of the patient must take cognizance 
of the existence of indefinite muscular pains, articular swellings, 
joint stiffness, the so-called growing pains, the previous occurrence 
of attacks of tonsillitis, chorea, torticollis, and erythemas. When 
the suspicion is once aroused that there is a rheumatic tendency, 
any symptoms which arise and cannot be definitely explained 
should be suggestive of rheumatism. 

An attack of rheumatism may begin very insidiously, with 
slight fever, some indisposition, and anorexia. One or more 
joints may be tender, but at times to such a slight degree that 
it is overlooked, or the tenderness may rapidly shift from one 
joint to another. When there is joint or muscular tenderness, 
beginning in such a way and without a clear history of injury, 
it must always arouse suspicion of a rheumatic origin. At other 
times the joints may simply be somewhat stiffened. When the 
infection is of such a nature as the foregoing, it is more often 
overlooked than mistaken for other conditions. 

In other instances the attacks may be rather sharp and severe 
and the joints acutely swollen and painful. In such cases the 
temperature is usually high and prostration more marked, and, 
instead of clearing up in a week or two, the condition persists for 
from three to five weeks. In these instances the heart condition 
may be serious from the very start and anemia becomes a marked 
feature. Anemia is usually so sudden and severe that there is 
danger of mistaking the anemic murmurs for those due to endo- 
carditis. 

In the cases which exhibit serious cardiac changes there may 
at times be observed the development of subcutaneous nodules 
which vary in size up to that of a small nut. They may persist 
for months and are always indicative of a tendency to serious 
cardiac involvement. 



CRETINISM 



0^0 



The infrequency with which rheumatism occurs in infancy 
should always make one very guarded in the diagnosis of the 
disease during that period of life. The commonest mistake is to 
consider the symptoms which are due to scurvy in the infant as 
dependent upon rheumatism. If the pain and tenderness are 
confined to the lower limbs, even without the usual associated 
affection of the gums, and the patient is an infant, it is safe to 
consider the symptoms as due to scurvy, if an etiologic factor be 
present. It may be that the evidences of pain upon handling may 
be attributed to rachitis, but in such cases the other evidences of 
rachitis are always marked enough to allow of no error. 

The symptoms of rheumatism are so variable, and so insignifi- 
cant at times, the course so indefinite, and the results to the heart 
so disastrous, that much depends upon a recognition of the 
hereditary tendency to the disease for its early diagnosis. 



CRETINISM 

When fairly well developed, there is little probability of cretinism 
being mistaken for any other condition. It is during the period 
of later childhood that the cases are more easily recognized. 
During the early developmental period of life, when the stunted 
growth and mental condition of the infant are not in such strong 
contrast to what is normal, the difficulties of early recognition 
are more marked. 

While the mental condition of these children is very striking, 
it is only a part of the general arrest of proper development. 
In sporadic cretinism there is a complete absence of the thyroid 
gland (either actual or functional), and this is determined by 
the clinical factors which are evidenced. The chief of these 
is the arrest of development, while the facial expression, the 
thick and everted lips, the broadened nose with a depressed 
root, the enlargement of the tongue, the lordosis and peculiar 
dryness and cyanosis of the skin, add to the picture. Usually 
the limbs are much shorter in proportion to the body than is 
natural. The condition would be much more readily recognized 
if the strong hereditary influence was recalled, and if every baby 
whose mental development did not seem to keep pace with its 



526 CRETINISM 

physical growth (early in the condition, the infant appears some- 
what stunted, but fat) was looked upon as a suspect. 





Fig. 158. — Cretinism (side view). Fig. 159. — Cretinism (front view). 

The value of the administration of some preparation of the 
thyroid gland would soon aid in determining the real cause of 
the symptoms. 



NDEX 



Abdomen, ascites, 134 

distended bladder, 137 

enlarged liver, 144, 145, 146, 147, 
148 
spleen, 149 

enlargement of, 133 

examination of, 130 

hydronephrosis, 136 

ileocolitis, chronic, 166 

inspection of, 130 

normal, 131 

pain in, 123 

palpation of, 132 

percussion of, 135, 136, 137 

peritonitis, non-tuberculous, 138 
tuberculous, 138 

regions of, 131 

retroperitoneal sarcoma, 143 

thickened wall, 130 

thin-walled, 130 

tumors of kidneys, 143 

tympanites, 133 
Abscess, brain, 318 

liver, 149 

retro-esophageal, 99 

retropharyngeal, 83 
Adenoids, 50, 78 

examination for, 52, 80 

facial expression in, 26, 51 

mental condition in, 79 

vertigo from, 321 
Age, influence on disease, 20 
Albuminuria, 303 

accidental, 303 

functional, 304 

physiologic, 304 

renal, 304 
Alimentary canal, anatomy of infan- 
tile, 171 
bacteria of, 155, 156 



Alimentary canal, time of passage of 
food through, 170, 172 
tuberculosis of, 163 
Amaurotic family idiocy, 383 
Amyloid disease, 147 
Anasarca, 259 
Anemia, 264 

chlorosis, 270 

dry cough in, 181 

etiology of, 265 

leukemia, 269 

murmurs, 285 

pernicious, 267 

simple, 265 
Anemic murmurs, 285 
Angiomata cavernosa, 250 
Angioneurotic edema, 259 
Anorexia, 100 
Anuria, 295 
Anus, atresia of, 111 

fissure of, causing constipation, 167 
pain, 167 

hemorrhage from, 169 

itching of, 174 
Apex-beat, 271 

displacement of, 272 

position of, 271 

position for examination of , 273 
Aphthae of palate, 69 
Appendicitis, 125 

position assumed in, 25 
Appetite, 99 

increased, 101 

loss of, .100 

perverted, 102 
Approach to child, IS 
Arthritis, acute, 45S 
Ascaris lumbricoides, 174 
Ascites, 134 
Asthma. 20^ 



5-7 



5^8 



INDEX 



Asthma, facial expression in, 210 

simulating bronchopneumonia, 210 

sputum in, 210 
Asymmetry of chest, 198 

of head, 40 

of limbs, 370, 375 
Ataxia, 392 

hereditary, 393 
Athetoid movements, 345 
Athetosis, movements, 345 
Atresia ani, 1 1 1 

as cause of constipation, 111 
as cause of vomiting, 111 



Bacteria, intestinal, 155, 156 
Balanitis, 292 
Baldness of occiput, 42 
Bed-wetting, 296 
Birth-marks, 250 
Bladder, distended, 137 
Blood in stool, 169 

in vomitus, 119 
Body weight, 29 
Bone disease, 458 
syphilitic, 474 
tubercular, 460 
Bones and joints, 457 
Bradycardia, 289 
Brain, abscess of, 318 

inflammation of membranes, 402 

tuberculosis of, 403 

tumors of, 316 
Breast, inflammation of, in new-born, 

198 
Breathing, abdominal type, 203 

cerebral group, 408 

Cheyne-Stokes, 203 

rhythm of, 202 

stertorous, 204 

stridulous, 204 

thoracic type, 203 
Bronchiectasis, 193 
Bronchitis, acute, 187 

cough in first stage, 181 

cough in latter stages, 181, 187 

mild form in older child, 189 

mild infantile form, 187 

severe form in older child, 189 

severe infantile form, 188 



Bronchitis, chronic, 191 
Bronchopneumonia, 219 

auscultation results in, 222 

causes of, 220 

cough in, 181, 182 

d'agnosis of, 223 

examination in, 221 

percussion results in, 221 



Calculi, urinary, 291 
Canker, 67 

Caput succedaneum, 45 
Caries of spine, 46 1 

as cause of abdominal pain, 129 
Catarrh of intestines as cause of pain, 
129 
of stomach, 118 
Cephalhematoma, 46 
Cerebral abscess, 318 

tumor, 316 
Chest, 195 

auscultation of, 206 
bulging of, 201 
depressions of, 201 
edema of, 258 
emphysematous, 199 
examination of, 195 
flat, 199 
funnel, 199 
inspection of, 196 
movements in disease, 201 
in health, 197 
increased, 202 
palpation, 205 
percussion, 205 
pigeon, 199 
rachitic, 199 

restrained movements, 209 
shape of, in disease, 198 

in health, 196 
size of, in disease, 198 

in health, 197 
skin in disease, 198 

in health, 196 
subcutaneous tissues of, in disease, 
198 
in health, 196 
unilateral contraction, 200 
enlargement, 200 



INDEX 



529 



Cheyne-Stokes respiration, 203 
Chicken-pox, 509 
Child, approach to, 18 

peculiarities of, 18 
Chills, 413 
Chlorosis, 270 
Cholera infantum, 160 

facial expression in, 27 
Chorea, 341 

hysterical, 371 

nollis, 371 

paralysis of, 370 
Chvostek's symptom in tetany, 340 
Cicatrices, 260 
Coldness, general, 262 

localized, 262 
Colic, 123 

appendicular, 125 

flatulent, 124 

intestinal, 124 
Coma, 323 

cerebral inflammation, 323 

epilepsy, 324 

febrile diseases, 323 

insolation, 324 

poisoning, 323 

traumatism, 323 

uremia, 324 

vigil, 323 
Consciousness, disturbances of, 323 

diagnostic significance, 323 
Constipation, chronic, 170 
anal fissure as cause, 171 
causes of, 171 
diagnosis, 170 
influence of diet, 171 
of habit, 171 

impacted feces, 114 

intussusception, 112 

malformations, 111 

obstinate, 111 

pyloric stenosis, 114 

strangulated hernia, 114 
Convulsions, 326 

cerebral, 332 

choreic, 343 

epileptic, 335 

febrile, 329 

hysteric, 338 

influence of age, 327, 328 
34 



Convulsions, influence of heredity, 
334 
of rachitis, 333 
in newly born, 328 
in very young infant, 20 
tetanic, 339 
with fever, 329 
without fever, 333 
Coryza, 49 
Cough, 180 
cardiac, 183 
dry, 181 
hacking, 182 
inability to, 183 
laryngeal, 182 
moist, 181 

non-respiratory, 180 
paroxysmal, 182 

prominent symptom of disease, 1 83 
respiratory, 180 
suppressed, 182 
violent, 186 
Coughing, act of, 180 
Cramp, 123. See also Colic. 
Cranial contours, 41 
Craniotabes, 45 
Cretinism, 525 
expression in, 26 
facies of, 29 
Croup, 88 
Cry, 176 

continued loud, 176 
low, 177 
suppressed, 177 
loud, 176 

lusty, at birth, 176 
short violent, 177 
weak, at birth, 176 
Curshmann's spirals, 210 
Cutaneous surface, 233 
cyanosis, 235 
eruptions, 243 
examination of, 233 
pallor, 233 
rashes, 243 
redness of, 235 
yellow tint of, 234 
Cyanosis, 235 

circumscribed, 256 
Cyst, hydatid, 148, 149 



53o 



INDEX 



Cyst, ovarian, 143 
Cystitis, 294 



Defecation, painful, 167 
Delirium, 324 
Dentition, 22, 23 

delayed, 23 
Dermatitis exfoliativa, 237 

gangrenosa, 245 
Diabetes insipidus, 299 
Diarrhea, acute, 155 
causes of, 155 
diagnosis of, 153 
eliminative, 157 
fatty, 157 

in gastro-enteric infection, 158 
in ileocolitis, 162 
in intestinal indigestion, 157 
nervous, 156 
pain in, 154 

periodic, in malaria, 154 
scarlet fever, 109 
chronic, 163 
causes of; 163 
in ileocolitis, 165 
in intestinal indigestion, 166 
in malaria, 166 
in tuberculosis, 165 
diagnosis, 153 
Diazo reaction, value of, 425 
Dilatation of heart, 272, 273 

of stomach, 118 
Diphtheria, 513 

cardiac paralysis, 369, 518 
laryngeal, 517, 518 
nasal, 517 
paralysis, 367 
pharyngeal type, 5 1 7 
Diphtheritic paralysis, 367 
cardiac, 369, 518 
respiratory, 369, 520 
Diplegia, 356 
Discharge from nose, 48 
acute, 49 
chronic, 54 
Diseases with cough as prominent 

symptom, 183 
Distended bladder, 137 
Drowsiness, 38, 323 



Dysphagia, 95 

congenital, causes of, 97 

from foreign body, 96 

from inflammation, 96 

from pressure, 96 

from spasm, 96 
Dyspnea, 208 

as evidence of cardiac disease, 209 

from asthma, 209 

from exertion, 208 

from hay-fever, 210 

from pulmonary emphysema, 211 

inspiratory, 209 

paroxysmal, 209 
Dystrophy, muscular, 386 
Dysuria, 290 



Echinococcus, 148 
Eczema, 250 

intertrigo, 252 

pustular, 252 

rubrum, 251 

seborrheic, 252 
Edema, 256 

anasarca, 259 

angioneurotic, 259 

general, 259 

localized, 257 
arm, 258 
eyelid, 258 
face, 258 
feet, 258 
leg, 258 
neck, 258 
Emphysema of lung, 2 1 1 

of skin, 263 
Emphysematous chest, 199 
Encephalocele, 46 
Enchondromata, 474 
Endocarditis, 279 

acute, 279 

malignant, 280 
Enlargement of abdomen, 133 

of chest, 198 

of head, 41, 42 

of heart, 272, 273 

of liver, 144 

of lymphatic glands, 477, 478 

of scrotum, 309 



INDEX 



531 



Enlargement of spleen, 149 

of stomach, 118 
Enteric fever, 420 

epistaxis suggestive of, 420 
neck rigidity in, 353 
splenic enlargement in, 421 
temperature of, 421 
value of diazo reaction, 425 
of Widal test, 425 
Enterocolitis, 162 

localized flatulence in, 155 
Enuresis, 296 
Epidemic cerebrospinal meningitis, 

410 
Epigastric pain, 398 
Epilepsy, 335 

convulsions of, 335 

grand mal, 335 

Jacksonian, 337 

petit mal, 336 
Epistaxis, 56 

general causes of, 57 

local causes of, 58 

typhoidal, 420 
Erb's symptom in tetany, 340 
Erosions of genitals, 293 
Eructation, 104 
Eruptions, 236 

crusty, 245 

erythematous, 237, 242 

medicinal, 242, 245 

papular, 244 

pustular, 245 

scaly, 245 

vesicular, 243 
Eruptive diseases, 481 
Erythema, 237 

localized, 239 

medicinal, 242 

morbilliforme, 490 

multiforme, 240 

of newly born, 233, 237 

nodosum, 241 

scarlatiniforme, 502 
Esophagitis, 98 

acute catarrhal, 98 

corrosive, 98 
Esophagus, 98 

diseases of, 98 

malformations of, 98 



Examination, 17 
abdomen, 130 
adenoid vegetations, 52, 80 
apex-beat of heart, 273 
chest, 195 
children, 17 
fauces, 72 
head, 40 
heart, 271 
lips, 59 
liver, 144 
mouth, 59 
nose, 48 
pharynx, 72 

retropharyngeal lymphadenitis, 83 
spleen, 149 
tongue, 61 
urine, 303 
Exanthemata, acute infectious, 481 
etiology, 481 

general considerations, 481 
incubation periods, 481, 482 
Exfoliative dermatitis, 237 
Expression of face, 25 
anxious, 27 
idiotic, 26 
listless, 26 
normal, 26 
normal, plus twitching, 26 

with parted eyelids, 26 
old, 27 
vacant, 26 
Expressionless face, 27 
Eye, abnormal movements, 346 
Eyelid, edema of, 258 



Face, edema of, 258 

expression of, 25, 26, 27 

expressionless, 27 

painful disfiguration of, 27 
Facies of cretinism, 29 

of disease, 28 

of malaria, 28 

of mouth-breathers, 28 

of nephritis, 28 

of pertussis, 28 

of syphilis, 28 

of tuberculous bone disease, 28 
Family history, 21 



532 



INDEX 



Fat in stool, 157 
Fatty diarrhea, 157 
Fauces, diseases of, 74 

examination of, 72, 73 

normal condition of, 73 
Favus, 247 
Feces, impacted, 114 

incontinence of, 166 

normal, 153 
Feet, edema of, 258 
Fever, 413 

causes of, 416 

continued, 418 

diagnostic significance, 416 

enteric, 420 

intermittent, 418 

malarial, 426 

remittent, 419 

scarlet, 496 

significance of type of, 417 

symptoms of, 415 
Flat chest, 199 
Flatulence in diarrhea, 155 

localized, 155 
Flatulent colic, 124 
Follicular tonsillitis, 74 
Fontanels, 43 

bulging, 44 
and tense, 44 

delayed closure of, 43 

murmuring, 45 

sunken, 44 
Food, estimation of time of passage 
through alimentary canal, 1 70, 1 72 

in stool, 158, 159, 164 

in vomitus, 121 
Foreign body in larynx, 92 

in nose, 55 
Fractures, 459 
Fremitus, bronchial, 205 

friction, 205 

hydatid, 149 

vocal, 205 
Friction fremitus, 205 
Funnel chest, 199 
Furunculosis, 262 



Gangrenous dermatitis, 245 
stomatitis. 70 



Gaseous eructations, 104 
Gastralgia, 400 
Gastric catarrh, 118 

dilatation, 118 
Gastritis, acute, 116 

chronic, 118 

croupous, 116 

suppurative, 117 

toxic, 117 
Gastroduodenitis, 117 
Gastro-enteric infection, acute, 158 
Genitals, erosions of, 293 

itching about, 174 
Glands, lymphatic, 477 
drainage areas of, 479 
enlargement of, 477, 478 
situation of, 479 
Glossitis, acute, 65 
Glottis, edema of, 91 
Gluttony, 101 
Grand mal, 335 
Green stools, 154, 158 
Groin, glandular enlargement in, 480 



Habit as cause of constipation, 171 

spasm, 344 
Hare-lip, 59 
Hay-fever, 210 
Head, 40 

abnormal fixity, 352 

asymmetry of, 40 

baldness of, 42 

contours of, 41 

enlargement of, gradual, 41 
rapid, 42 

nodding, 345 

shape of, 40 

size of, 40 

compared with chest, 41 
small, 42 

sweating of, 42 

tumors of, 45 

when first held erect, 23 
Headache, 312 

acute, 312 

chronic, 314 

febrile, 312 

from disease of organs of special 
sense, 314, 315 



INDEX 



533 



Headache, meningeal, 313 

toxic, 313 

tumors of brain, 315 
Heart, apex-beat, displacement of, 
272 
position of, 271 

auscultation of, 274 

congenital disease of, 285 
cyanosis in, 236, 285 

dullness, absolute, 274 
relative, 274 

examination of, 271 

functional disturbances of, 284 

inspection, 272 

murmurs, 283 

palpation, 273 

percussion, 273 

valvular disease, chronic, 280 
Heat, general, of skin, 262 

local, 262 
Hematemesis, 119 

causes of, false, 120 
true, 120 

false, 119 

in hemorrhagic disease, 120 

in malnutrition, 121 

in rubeola, 120 

in syphilis, 120 

in variola, 120 

true, 120 
Hematuria, 305 

in sarcoma, 142 
Hemoglobinuria, 306 
Hemorrhage, cutaneous, 253 

meningeal, 44 

nasal, 56 

rectal, 169 

stomach, 119 
Hemorrhagic purpura, 254 
Henoch's purpura, 256 
Hepatitis, suppurative, 146 
Hereditary spastic paralysis, 379 
Hernia, strangulated, 114 
Herpes, 243 

facialis, 243 

frontalis, 243 

of lips, 60 

of vulva, 293 

zoster, 243 
Hiccough, 346 



History, family, 21 

of present illness, 19 

of previous condition, 19, 21 
Hodgkin's disease, spleen in, 152 
Holding breath, 92 
Hunger, cause of cry, 176 

of restlessness, 37 
Hydatid resonance, 149 

thrill, 149 
Hydrencephalocele, 46 
Hydrocele, 309 

congenital, 309 

encysted, 310 

of cord, 310 
Hydrocephalus, 44, 403 

cranial contours in, 41 
Hydronephrosis, 136 
Hydrophobia, 350 
Hydrothorax, 232 
Hyperpyrexia, 413 

causes of, 416 

diagnostic significance of, 416 

symptoms of, 416 

type, significance, 417 
Hypertrophy, cardiac, 272, 273 

of tongue, 59 
Hypochondriac bulging, 201 
Hypostatic pneumonia, 228 
Hysteria, 338 
Hysteric convulsions, 343 

spasms, 338 



Ichthyosis, 245 
Icterus gravis, 234 

neonatorum, 20, 234 
Idiocy, amaurotic family, 383 
Ileocolitis, acute, 161 
follicular type, 162 
membranous, 162 
chronic, 164 
Impacted feces, 114 
Impetigo contagiosa, 246 
Inanition, acute, 35 

rhinitis of, 4 C ) 
Incontinence, fecal, 166 
in epilepsy, 167 
transient, 166 
of urine, 296 
Indigestion, disturbed sleep of, 37 



534 



INDEX 



Indigestion, gastric, acute, 115 
chronic, 118 
intestinal, acute, 157 
chronic, 164 
Infant, examination of, 17 

peculiarities of, 18 
Infantile cerebral paralysis, 373 

acute acquired form of, 373 

apparent, 383 

atrophic, 386 

flaccid paralysis, antenatal 

form, 367 
natal group, 372 
prenatal group, 372 
spinal paralysis, 359 

atrophic changes in, 360 
causes of, 359 
diagnosis of, 361 
mode of onset, 359, 360 
Infection, acute gastro-enteric, 158 
Infectious exanthemata, acute, 481 
general considerations, 481 
incubation periods, 481, 482 
Influence of diet in constipation, 171 

of habit, 171 
Insomnia, 37 
Intermittent fever, 418 
Intertrigo, 252 
Intestinal bacteria, 155, 156 
Intestine, position in early life, 171 
stenosis of, 112 
tuberculosis of, 163 
Intussusception, 112 

causing abdominal pain, 129 
constipation, 112, 113 
vomiting, 112, 113 



Jaundice, 234 

Joints, 457 

apparent paralysis in diseases of, 

383 
syphilitic disease of, 474 
tuberculous disease of, 460 



Kernig's sign, 408 
Kidney, congestion of, 297 

acute, 297 

chronic, 297 



Kidney, degeneration of, 298 

inflammations of (nephritis), 298, 
299 

tuberculosis of, 308 

tumors of, 141 
Koplik's spots, 485 
Kyphosis causing chest deformity, 

199 



Landry's paralysis, 367 
Laryngismus stridulus, 92 
Laryngitis, acute catarrhal, 90 

chronic, 94 

membranous, 88 

submucous, 91 

syphilitic, 94 

tuberculous, 95 
Larynx, catarrhal inflammation of, 
90 
acute, 90 
chronic, 94 
spasm of, 86 

foreign body in, 92 

causing cough, 185 

stenosis of, 85 

syphilis of, 94 

tuberculosis of, 95 

tumors of, 95 
Leg, edema of, 258 
Leptomeningitis, 402 
Leukemia, 259 

splenic enlargement in, 152 
Lice, 250 

Lingua geographica, 64 
Lips, 59 

color of, 60 

eczema of, 61 

eruptions about, 60 

herpes of, 60 

open, 60 

swollen, 60 

twitching, 60 

unilateral deviation of, 60 
Liver, amyloid disease of, 147 

cirrhosis of, 147 

congestion of, 1 45 

contracted, 147 

echinococcus, 148 

enlargement, acute. 145 



INDEX 



535 



Liver, enlargement, chronic, 147 
fatty, 148 

infectious, acute, 146 
leukemic, 148 
suppurative, 146 
syphilitic, 149 
tumors of, 149 
Lobar pneumonia, 212 

anomalous onset of, 213 

types of , 2 1 2 
auscultation in, 215 
cerebral form of, 218 
diagnosis of, 216 
examination in, 215 
percussion signs of, 215 

during resolution, 216 
vomiting at onset of, 109 
Weill's sign in, 214 
Localized heat of skin, 262 

redness of skin, 235 
Lung, auscultation of, 206 

inflammations of, 212, 219, 228 
percussion of, 207 
tuberculosis of, 440 
Lymphatic glands, 477 
drainage areas of, 479 
enlargement, acute, 477 

chronic, 478 
situation of, 479 



Malaria, 426 

facies of, chronic, 28 

hematuria in, 305, 306 

periodical diarrhea, 154, 165 

splenic enlargement, 152 
Malformations of esophagus, 98 

of lips, 59 

of mouth, 59 

of tongue, 59 
Malnutrition, 29, 30 

in chronic ileocolitis, 164 

in tapeworm, 175 
Marasmus, 34 

facial expression in, 27 

loss of weight in, 34 

simulating tuberculosis, 34 
Mastitis neonatorum, 198 
Measles, 483 

complications of, 494 



Measles, deviations from usual course 
during convalescence, 493 
during eruption, 492 
during incubation, 491 
Membrane in vomitus, 121 
Membranous laryngitis, 88 
Meningeal hemorrhage, tense bulging 

fontanel in, 44 
Meningitis, 402 

epidemic cerebrospinal, 410 

facial expression in, 26 

leptomeningitis, 402 

pachymeningitis, 402 

posterior basic, 406 

suppurative, 409 

tense fontanel in, 44 

tuberculous, 403 
Meningocele, 46 
Migraine, 319 

unilateral redness of face in, 235 
Mild bronchitis, 187, 189 
Miliaria papulosa, 244 

rubrum, 244 
Milk in vomitus, 121 
Moisture of skin, 261 
diminished, 261 
increased, 261 
Monoplegia, 256 
Mouth-breathers, facies of, 28 
Mouth, diseases of, 65 
Multiple neuritis, 364 
Murmuring fontanel, 45 
Muscles, 

flaccid, 358 

spastic, 372 
Muscular atrophy, 389 

dystrophy, 386 
Myelitis, transverse, 379 
Myotonia, congenital, 347 
Myxedema, 259 



Nasal cavity, discharge from, 49 
examination of, 48 
hemorrhage of, 56 
Navel, bleeding from, 130, 131 
healing of, 130 
protruding, 131 
Neck, edema o\, 25$ 

musculature, rigidity o\, 352 



536 



INDEX 



Nephritis, acute diffuse, 298 

chronic interstitial, 299 
parenchymatous, 299 

facies of, 28 
Nervous system, facial expression in 

diseases of, 26 
Neuralgia, supra-orbital nerve, 320 
Neuritis, multiple, 364 
Nevi, 250 

Newborn, erythema of, 233, 237 
Night- terrors, 37 
Noma, 70 
Nose, discharge from, 49 

examination of, 48 

foreign body in, 55 

pain about region of, 48 

polypi in, 56 

stenosis of, 48 
Nystagmus, 346 

Observation, value of, 18 
Obstruction, intestinal, 114 

nasal, 48 
Occipital baldness, 42 
Omphalitis, 132 
Open lips, 60 
Orchitis, 3 1 1 

Osteomyelitis, acute, 458 
Ostitis, infective, 458 
Otitis, acute, 399 
Oxyuris vermicularis, 173 

Pachymeningitis, 402 
Pain, 396 

abdominal, 123 

examination for, 123 

arm, 399 

character of, 397 

chest, 398 

defecation, 167 

diffused, 398 

ear, 399 

epigastrium, 398 

evidenced by cry, 176, 177, 178 
by position, 24 

fauces, 72 

head, 312 

joints, 399 

leg, 399 



Pain, mode of onset, 397 

nose, 48 

pharynx, 72 

pneumonia, 213 

precordial, 398 

site of, 398 

spinal, 399 

substernal, 399 

time of occurrence, 397 

urination, 290 
Painful defecation, 167 

urination, 290 
Palate, aphthae of, 69 

cleft, 59 
Pallor of skin, 233 
Paralysis, 356 

acute acquired cerebral, 373 
ascending, 367 

choreic, 370 

classification of, 356 

diphtheritic, 367 
hoarseness in, 179 
vomiting in, 107 

flaccid, 358 

functional, 384 

hereditary spastic, 379 

hysteric, 385 

infantile cerebral, 372 
antenatal form, 367 
facial, 388 
spinal, 359 

juvenile type, 388 

Landry's, 367 

multiple neuritis, 364 

muscular dystrophy, 386 

peroneal form, 389 

pseudohypertrophic, 387 

spastic, 372 

spinal caries, 380 

syringomyelia, 390 

transverse myelitis, 379 

unclassified, 383 
Paraplegia, 356 

Parasites, causing abdominal pain, 
129 
persistent malnutrition, 175 
reflexes, 175 
vomiting, 174 

intestinal, 173 
Paresthesia, 320 



INDEX 



537 



Paresthesia, persistent, 32 1 

transient, 321 
Pediculosis, 250 
Pericarditis, acute, 276 

causes of, 276 

chronic, 278 

posture in, 25 
Perinephritis, position assumed in, 24 
Periodicity of symptoms, 427 
Periostitis, syphilitic, 475 
Peritonitis, acute, 128 

chronic non- tuberculous, 138 

tuberculous, 138 
Perleche, 61 
Perspiration, 261 

diminished, 261 

increased, 261 
Pertussis, 183 

catarrhal stage of, 183 

character of cough in, 184, 185 

facies of, 28 

resolving stage, 1 84 

spasmodic coughing stage, 184 
Petit mal, 336 
Pharyngitis, acute, 81 

cause of vomiting, 107 

chronic, 82 
Pharynx, 72 

diseases of, 73 

examination of, 72, 73 

normal condition of, 73 
Phlegmons of back, 25 
Photophobia, posture in, 25 
Pica, 102 

Pigeon breast, 199 
Pigmentation of skin, 250 
Pin-worms, 173 
Pleuritis, 229 

auscultation in, 230, 231 

dry form of, 229 

friction rub in, 230 

purulent, 231, 232 

posture in, 24 

Pleuropneumonia, 227 

Pneumatocele cranii, 47 

Pneumonia, hypostatic, 228 

lobar, 212 

anomalous onset, 213 

types, 212 
auscultation in, 215 



Pneumonia, lobar, cerebral type, 
218 
diagnosis of, 215 
percussion signs of, 215, 216 
vomiting in, 109 
Weill's sign, 214 
Poisoning by strychnine, 350 
Polypi, nasal, 56 

rectal, 169 
Posterior basic meningitis, 406 
Posture, 24 

abdominal, 25 

dorsal, 24 

forced, 25 

general, 24 

of head in retropharyngeal lymph- 
adenitis, 84 

side, 24 

sitting, 25 

upright, 25 
Pott's disease, 461 
Precordia, bulging, 201 
Present condition of child, 19 
Previous condition of child, 19, 
21 
in disease, 23 
Proctitis, 168 

cause of painful defecation, 167 
of tenesmus, 168 

membranous, 168 

ulcerative, 168 
Pruritus, 249 

localized, 249 

nasal, 249 

opium as cause, 249 
Psoriasis, 248 

Pulmonary emphysema, 211 
Pulse, 288 

irregular, 289 

rate, decreased, 289 
increased, 288 
Purpura, 253 

hemorrhagica, 254 

Henoch's, 256 

simple, 253 
Pus in vomitus, 1 2 1 
Pustular eczema, 250 
Pyelitis, 307 
Pyloric stenosis, 114 
Pyuria. 307 



538 



INDEX 



Quinsy sore throat, 75 



Rachitis, 444 

anemia marked in, 445 

cause of convulsions, 333 

craniotabes in, 446 

splenic enlargement in, 151 

walking late in, 23 
Rashes, 236. See also Eruptions. 
Rectal polypi, 169 

Rectum, congenital malformations, 
111 

position in early infancy, 171 

temperature taken by, 414 
Redness of skin, 242 

localized, 235 
Respiration, 201 

abdominal type of, 203 

alterations in rhythm, 202 

Cheyne-Stokes, 202, 203 

influenced by disease, 201 

labored, 208 

puerile, 207 

sighing, 204 

stertorous, 204 

stridulous, 204 

thoracic, 203 

various types of, 203 
Retro-esophageal abscess, 99 
Retropharyngeal lymphadenitis, 83 
causing laryngeal stenosis, 92 
examination to detect, 83 
position of head in, 84 
Rheumatism, 522 

cardiac changes in, 523 

diagnosis of, 522 

early recognition important, 522 

estimation of functional capacity, 
522 

importance of family history, 523 

symptomatology, 523 
Rhinitis, acute, 49 

atrophic, 55 

chronic, 54 

gonorrheal, 50 

membranous, 53 
Rigidity of neck musculature, 352 
acute contracture, 352 
chronic contracture, 354 



Ringworm, 247 
Roseola, 239 

sestiva, 239 

diagnosis of, 240 

syphilitic, 240 
Rotary spasm, 345 
Roundworms, 174 
Rubella, 494 
Rubeola, 483 

complications of, 494 

deviations from usual course, 491, 
492, 493 



Salivation in stomatitis, 68 
Sarcoma, 143 
Scabies, 249 
Scarlet fever, 496 

complications which modify, 500 
deviations from usual course in 
eruption, 500 
in incubation, 499 
diarrhea at onset, 109 
nephritis common in, 500 
otitis in, 501 
synovitis in, 500 
vomiting at onset, 109 
Scars, 260 
Scleroderma, 262 
Sclerema adiposum, 259 

neonatorum, 259 
Scoliosis from foreign body in bronchi, 
201 
in spinal caries, 461 
Scrofulosis, 442 
Scrotum, enlargement of, 309 
Seborrhea, 246 
Seborrheic eczema, 252 
Skin, 233 

dryness of, 261 
emphysema of, 263 
cicatrices, 260 
coldness of, 262 
color of, 233 
cyanotic, 235 
red, 235 
yellow, 234 
eruptions of, 236 
erythematous, 237 
papular, 244 



INDEX 



539 



Skin, eruptions of, pustular, 245 
scaly, 245 
vesicular, 243 
with crusts, 245 

heat of, 261 

hemorrhage into, 253 

moist, 261 

pallor of, 233 

pigmentation of, 250 

rashes of, 236 

swellings of, 262 
Sleep, 36 

disturbed, 37 

excessive, 38 

normal, 36 

restless, 37 

talking during, 39 

time spent in, 36 

uneasy, 37 

walking in, 38 
Somnolence, 323 
Spasms, 326 

athetoid movements, 345 

athetosis movement, 345 

choreic, 341 

habit, 344 

head nodding, 345 

hiccough, 346 

myotonia, congenital, 347 

nystagmus, 346 

rotary, 345 

strychnine poisoning, 350 

tetanic, 339 
Spinal caries, 461 
Spleen, enlargement of, 149 
acute, 150 

from congenital defects, 151 
chronic, 151 

new-growths, 152 
Spondylitis, cervical, causing neck 

contracture, 355 
Sprue, 67 
Sputum, asthmatic, 210 

fetid, 193 

in tuberculosis, 441 
Stenosis of intestine, 112 

laryngeal, 86 
acute, 86 
chronic, 94 
congenital, 95 



Stenosis, nasal, 48 

pyloric, 114 
Stomach, dilatation of, 118 
diseases of, 115 
hemorrhage of, 122 
position of, in infancy, 104 
Stomatitis, 66 

acute catarrhal, 66 
aphthosa, 67 
gangrenous, 70 
gonorrheal, 66 
membranous, 71 
mycosa, 67 
syphilitic, 68 
ulcerative, 69 
Stools, color of, 154, 158 
fatty, 157 

food in, 158, 159, 164 
in acute gastric indigestion, 115 
in gastro-enteric infection, 159 
in ileocolitis, chronic, 165 
in indigestion, acute intestinal, 158 

chronic intestinal, 165 
membrane in, 163 
mucus in, 159, 175 
normal condition, 153 
rapid passage in proctitis, 169 
watery, 156 
Strangulated hernia, 114 
Stridor, congenital laryngeal, 95 
Stupor, 323 
Sudamina, 244 
Sunken fontanel, 44 
Suppurative gastritis, 117 
hepatitis, 146 
meningitis, 409 
Sweating of head, 42 
Swollen lips, 60 
Syphilis, hereditary, 450 
bony changes in, 455 
diagnosis from acquired type, 

450 
eruption in, 453 
facial expression, 27 
facies of, 28 

methods of acquisition, 451 
rhinitis in, 54 
stomatitis oi, 68 
teeth in. 453 
voice, hoarse, 179 



54-0 



INDEX 



Syphilitic dactylitis, 476 

disease of bones, 474 

epiphysitis, 474 

laryngitis, 94 

osteoperiostitis, 475 
Syringomyelia, 390 



Tachycardia, 288 
Tapeworm, 175 
Teeth, eruption of, 22 

order of eruption of, 23 

syphilitic, 453 

time of eruption of, 22 
Temperature, 413 

determination of, 414 

elevated, 413 

lowered, 413 

subnormal, 419 
Tenesmus, rectal, 168 
Tenia, 175 

Testicle, strangulated, 114 
Tetanus, 348 

facial, 350 

neonatorum, 350 
Tetany, 339 

Chvostek's symptom in, 340 

Erb's symptom in, 340 

influence of age in, 340 
of rachitis, 340 

Trousseau's symptom in, 340 
Thirst, 103 
Thrush, 67 
Tinea capitis, 248 

circinata, 248 

corporis, 248 

favosa, 247 

trichophytina, 247 

tonsurans, 248 

unguium, 248 
Tongue, bifid, 59 

coated, 61 

color of, 63 

dry and glazed, 63 

epithelial desquamation of, 64 

hypertrophy of, 59, 63 

inflammation of, 65 

manner of clearing when coated, 
62 

strawberry, 62 



Tongue, ulcers of, 64 
Tongue-tie, 59 
Tonsillitis, acute, 74 

chronic, 77 

follicular, 74 

simple catarrhal, 74 

suppurative, 75 

ulceromembranous, 76 
Torticollis, 354 
Trachea, foreign body in, 185 
Tracheitis, 186 
Transverse myelitis, 379 
Trousseau's symptom in tetany, 340 
Tuberculosis, 431 

cerebral, 403, 438 

early auscultation valuable in, 432 

family history valuable in, 434 

intestinal, 163 

kidney, 308 

larynx, 95 

lung, 440 

marasmus type of, 433 

osseous system, 460 

peritoneum, 138 

typhoidal type, 434 
Tuberculous ankle-joint, 471 

bone-disease, 460 

dactylitis, 473 

elbow-joint, 472 

facies of, bone disease, 28 

hip-joint, 467 

knee-joint, 471 

meningitis, 403 

pneumonia, 436 

Pott's disease, 461 

sacro-iliac disease, 472 

shoulder-joint, 472 

spinal caries, 461 

sternoclavicular joint, 472 

wrist-joint, 472 
Tumor, abdominal, 133. See also 
Enlargement of Abdomen. 

of brain, 316 

of head, 45 

of kidney, 141 

of liver, 149 
Twitching lips, 60 
Tympanites, 133 

acute, 133 

chronic, 134 



INDEX 



541 



Typhoid fever, 420 

epistaxis common in, 420 
neck rigidity in, 353 
splenic enlargement, 421 
typical temperature of, 421 
value of diazo reaction, 425 
Widal test. 425 



Ulcerative proctitis, 168 
Unilateral deviation of lips, 60 

redness of face, 235 
Urethritis, 292 
Urinary calculi, 291 
Urination, 290 

difficult, 291 

frequent, 293 

painful, 290 
Urine, 301 

albumin in, 303 

blood in, 305 

blood-pigment in, 306 

chemical examination of, 303 

color of, 301 

excretion of, diminished, 297 
increased, 298 

incontinence of, 296 

odor of, 303 

pus in, 307 

quantity of, 302 

reaction of, 302 

retention of, 294 

scanty excretion of, 295 

sediments in, 302 

specific gravity of, 302 

suppression of, 295 
Urticaria, 241 
Uvula, bifid, 59 
Uvulitis, acute, 83 



Value of diazo reaction, 425 

of Widal test, 425 
Valvular aortic insufficiency, 283 
stenosis, 283 
disease of heart, 280 
mitral insufficiency, 282 

stenosis, 282 
pulmonic insufficiency, 283 
stenosis, 283 



Valvular tricuspid insufficiency, 283 

stenosis, 283 
Varicella, 509 
Variola, 505 
abortive, 509 
confluent, 507 
discrete, 507 
eruption of, 506, 507 
malignant, 508 
modified, 508 
vomiting at onset of, 109 
Varioloid, 508 
Veins, distended, 260, 261 
Venous murmurs, 284 
Verruca, 263 
Vertigo, 321 
Vesical spasm, 294 
Vocal fremitus, 205 
Voice, 179 
hoarse, 179 
loss of, acute, 179 

chronic, 179 
nasal, 179 
Vomiting, 104, 105 

after coughing spell, 106 
appendicitis, 126 
associated with constipation, 111 
diseases of the stomach, 115 
impacted feces, 114 
intussusception, 112 
pyloric stenosis, 114 
rectal malformations, 111 
strangulated hernia, 114 
associated with fever, 108 
cerebral, 108 
cyclic, 1 1 
dietetic error at onset of fever, 

108 
lithemic, 110 
onset of peritonitis, 109 
.of pneumonia, 109, 212 
of scarlet fever, 109 
recurrent, 1 10 
toxemic, 110 
atresia ani, 1 1 1 
cough as a cause of. 121 
dilatation of stomach, 121 
gastritis, acute. 116, 121 

chronic. 1 1 S 
inanition, acute, 121 



542 



INDKX 



Vomiting, indigestion, acute gastric, 
115 
chronic gastric, 118 
intestinal, 165 
marasmus, 121 
pyloric stenosis, 121, 114 
with no fever, 105 

after coughing spell, 106 
diphtheritic paralysis, 107 
eye-strain, 107 
habit, 106 

intestinal parasites, 106 
neurotic, 106 
pharyngeal irritation, 107 
poisoning, 108 

stomach, overdistention, 106 
wrong handling of child, 121 
Vomitus, bloody, 119 
character of, 119 

in gastric catarrh, 118 

in gastric indigestion, chronic, 

118 
in gastritis, acute, 118 
in gastro-enteric infection, 159 
membrane in, 121 
pus in, 121 
with food and bile, 121 

and mucus, 121 
with uncoagulated milk, 121 
Vulva, herpes of, 293 
Vulvovaginitis, 292 



Walking, 23 

in sleep, 38 
Warts, 263 
Wakefulness, 37 
Weight, 29 

average, of infants, 30 

gain, 32 
rapid, 36 

loss, 30, 31, 32 
gradual, 32 
rapid, 35 
relative, 33 
steady, 34 

stationary, 35 
Weill's sign, 214 
Wetting of bed, 296 
Whooping-cough, 183 

catarrhal stage, 183 

character of cough, 184, 185 

facies in, 28 

resolving stage, 184 

spasmodic coughing stage, 184 
Widal test, value of, 425 
Worms, 173 

pin-, 173 

round-, 174 

tape-, 175 
Wryneck, 354 



Xeroderma pigmentosum, 250 



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Dr. McConnell has discussed his subject with a clearness and precision of 
style that render the work of great assistance to both student and practitioner. 
The illustrations, many of them original, have been introduced for their practical 
value. 



PATHOLOGY. 



Stengel's 
Text-Book of Pathology 

Just Issued— The New ^th) Edition 



A Text=Book of Pathology. By Alfred Stengel, M. D., Professor 
of Clinical Medicine in the University of Pennsylvania. Octavo volume 
of 979 pages, with 400 text-illustrations, many in colors, and 7 full-page 
colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 

WITH 400 TEXT-CUTS, MANY IN COLORS, AND 7 COLORED PLATES 

In this work the practical application of pathologic facts to clinical medicine 
is considered more fully than is customary in works on pathology. While the 
subject of pathology is treated in the broadest way consistent with the size of the 
book, an effort has been made to present the subject from the point of view of the 
clinician. In the second part of the work the pathology of individual organs and 
tissues is treated systematically and quite fully under subheadings that clearly 
indicate the subject-matter to be found on each page. In this edition the section 
dealing with General Pathology has been most extensively revised, several of the 
important chapters having been practically rewritten. A very useful addition 
is an Appendix treating of th' technic of pathologic methods, giving briefly the 
most important methods at present in use for the study of pathology, including, 
however, only those methods capable of giving satisfactory results. The book 
will be found to maintain fully its popularity. 



PERSONAL AND PRESS OPINIONS 



William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore, Md. 

" I consider the work abreast of modern pathology, and useful to both students and practi- 
tioners. It presents in a concise and well-considered form the essential facts of general and 
special pathologic anatomy, with more than usual emphasis upon pathologic physiology. 

Ludvig Hektoen, M. D., 

Professor of Pa th o logy , Rush Medical College, Chicago. 

" I regard it as the most serviceable text-book for students on this subject yet written by an 
American author." 

The Lancet, London 

"This volume is intended to present the subject of pathology in as practical a v 
sible, and more especially from the point of view of the 'clinical pathologist.' Th 
have been faithfully carried out, and a valuable text-book i- the result. We can most fa 
recommend it to our readers as a thoroughly practical work on clinical patho 



SAUNDERS' BOOKS ON 



Dtirck and liektoen's 

General Pathologic Histology 



Atlas and Epitome of General Pathologic Histology. By Pr. 

Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- 
toen, M. D., Professor of Pathology in Rush Medical College, Chicago. 
172 colored figures on 7 7 lithographic plates, 36 text-cuts, many in 
colors, and 353 pages. Cloth, $5 .00 net. In Saunders' Hand- Atlas Series. 

A NEW VOLUME— RECENTLY ISSUED 

This new Atlas will be found even more valuable than the two preceding 
volumes on Special Pathologic Histology, to which, in a manner, it is a com- 
panion work. The text gives the generally accepted views in regard to the signifi- 
cance of pathologic processes, explained in clear and easily understood language. 
The lithographs in some cases required as many as twenty-six colors to reproduce 
the original painting. Dr. Hektoen has made many additions of great value. 

W. T. Councilman, M. D., 

Professor of Pathologic Anatomy, Harvard University. 

" I have seen no plates which impress me as so truly representing histologic appearances 
as do these. The book is a valuable one." 

Howell's Physiology 



A Text=Book of Physiology. By William H. Howell, Ph.D., 
M. D., Professor of Physiology in the Johns Hopkins University, Balti- 
more, Md. Octavo of 904 pages, 272 illustrations. Cloth, $4.00 net. 

JUST READY— ENTIRELY NEW 

Dr. Howell has had many years of experience as a teacher of physiology in 
several of the leading medical schools, and is therefore exceedingly well fitted to 
write a text-book on this subject. Main emphasis has been laid upon those facts 
and views which will be directly helpful in the practical branches of medicine. At 
the same time, however, sufficient consideration has been given to the experimen- 
tal side of the science. The entire literature of physiology has been thoroughly 
digested by Dr. Howell, and the important views and conclusions introduced into 
his work. Illustrations have been most freely used. 
The Lancet, London 

" This is one of the best recent text-books on physiology, and we warmly commend it to the 
attention of students who desire to obtain by reading a general, all-round, yet concise survey of 
the scope, facts, theories, and speculations that make up its subject matter." 



PATHOLOGY. 



McFarland's 
Text-Book of Pathology 



A Text=Book of Pathology. By Joseph McFarland, M. D., Pro- 
fessor of Pathology and Bacteriology in the Medico-Chirurgical Col- 
lege of Philadelphia ; Pathologist to the Medico-Chirurgical Hospital, 
Philadelphia. Handsome octavo of 818 pages, with 350 illustrations, 
many in colors. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 

RECENTLY ISSUED— BEAUTIFULLY ILLUSTRATED 

This entirely new work is a plain account of the natural history of disease, and 
covers the field thoroughly, accurately, and completely. Being the work of a 
teacher who, as such, is eminently familiar with the needs of students, it is arranged 
in a manner and written in a style best suited to teaching purposes. Unlike most 
works on pathology, it treats the subject, not from the professor's point of view, 
but from that of the student, the author ever aiming to render most easy of com- 
prehension the many difficult theories of the science. The text is admirably eluci- 
dated by numerous excellent illustrations, many of them having been especially 
drawn. Indeed, this book of Dr. McFarland's will be found of inestimable value. 



OPINIONS OF THE MEDICAL PRESS 



American Medicine 

" We feel confident in saying no other recent treatise, not encyclopedic in character on any 
subject, contains so much direct and correlated information on the branch with which it 

Medical Record, New York 

"The long teaching experience which Dr. McFarland has had has well qualified him for 

the task of writing a text-book, . . . and he has done it well." 

Medical News, New York 

"This is truly an excellent text-book. . . . The illustrations are numerous and are excep- 
tionally good." 



SAUNDERS' BOOKS ON 



GET A ^ « # — THE NEW 

THE BEST /imeriCcMl STANDARD 

Illustrated Dictionary 

Just Issued— New (4th J Edition 



The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, and kindred branches; with over ioo new and 
elaborate tables and many handsome illustrations. By W. A. Newman 
Dorland, M. D., Editor of " The American Pocket Medical Diction- 
ary." Large octavo, nearly 850 pages, bound in full flexible leather. 
Price, $4.50 net; with thumb index, $5.00 net. 

Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest 

Possible Cost 
WITH 2000 NEW TERMS 

The immediate success of this work is due to the special features that distin- 
guish it from other books of its kind. It gives a maximum of matter in a mini- 
mum space and at the lowest possible cost. Though it is practically unabridged, 
yet by the use of thin bible paper and flexible morocco binding it is only i3^ 
inches thick. The result is a truly luxurious specimen of book-making. In this 
new edition the book has been thoroughly revised, and upward of two thousand 
new terms that have appeared in recent medical literature have been added, thus 
bringing the book absolutely up to date. The book contains hundreds of terms 
not to be found in any other dictionary, over 100 original tables, and many hand- 
some illustrations, a number in colors. 



PERSONAL OPINIONS 



Howard A. Kelly, M. D., 

Professor of Gynecology, Johns Hopkiiis University , Baltimore. 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 

J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.) 

Professor of Surgery, Harvard Medical School. 

" I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



EMBRYOLOGY. 



Heisler's 
Text-Book of Embryology 

The New (3d) Edition, Preparing 



A Text=Book of Embryology. By John C. Heisler, M. D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
Octavo volume of 440 pages, with. 200 illustrations, 32 of them in 
colors. 

WITH 200 ILLUSTRATIONS, 32 IN COLORS 

The fact of embryology having acquired in recent years such great interest 
in connection with the teaching and with the proper comprehension of human 
anatomy, it is of first importance to the student of medicine that a concise and 
yet sufficiently full text-book upon the subject be available. This new edition, 
when issued, will represent all the latest advances recently made in the science of 
embryology. Many portions will be entirely rewritten, and a great deal of new 
and important matter added. A number of new illustrations are being prepared 
which will prove valuable. The previous editions of this work filled a gap most 
admirably, and this new edition will undoubtedly prove even more valuable. 
Heisler's Embryology has become a standard work. 



PERSONAL AND PRESS OPINIONS 



G. Carl Huber, M. D., 

Professor of Histology and Embryology, University of Michigan, Ann Arbor. 
" I find the second edition of 'A Text-Book of Embryology' by Dr. Heisler an improve- 
ment on the first. The figures added increase greatly the value of the work. I am again 
recommending it to our students." 

William Wathen, M. D., 

Professor of Obstetrics, Abdominal Surgery, and Gynecology, and Dean, A' i 

Medicine, Louisville, Ay. 
" It is systematic, scientific, full of simplicity, and just such a work as a medical student 
will be able to comprehend." 

Birmingham Medical Review, England 

"We can most confidently recommend Dr. Heisler's book to the student of 
medicine for his careful study, if his aim be to acquire a sound and practical acqua 
the subject of embryology." 



SAUNDERS" BOOKS ON 



Mallory and Wright's 
Pathologic Technique 

Recently Issued— Third Edition, Revised and Enlarged 



Pathologic Technique. A Practical Manual for Workers in Patho- 
logic Histology, including Directions for the Performance of Autopsies 
and for Clinical Diagnosis by Laboratory Methods. By Frank B. 
Mallory, M. D., Associate Professor of Pathology, Harvard Univer- 
sity ; and James H. Wright, M. D., Director of the Clinico-Pathologic 
Laboratories, Massachusetts General Hospital. Octavo of 469 pages, 
with 138 illustrations. Cloth, $3.00 net. 

WITH CHAPTERS ON POST-MORTEM TECHNIQUE AND AUTOPSIES 

In revising the book for the new edition the authors have kept in view the 
needs of the laboratory worker, whether student, practitioner, or pathologist, for 
a practical manual of histologic and bacteriologic methods in the study of patho- 
logic material. Many parts have been rewritten, many new methods have been 
added, and the number of illustrations has been considerably increased. Among 
the many changes and additions may be mentioned the amplification of the de- 
scription of the Parasite of Actinomycosis and the insertion of descriptions of the 
Bacillus of Bubonic Plague, of the Parasite of Mycetoma, and Wright's methods 
for the cultivation of Anaerobic Bacteria. There have also been added new 
staining methods for elastic tissue by Weigert, for bone by Schmorl, and for con- 
nective tissue by Mallory. The new edition of this valuable work keeps pace 
with the great advances made in pathology, and will continue to be a most useful 
laboratory and post-mortem guide, full of practical information. 



PERSONAL AND PRESS OPINIONS 



Wm. H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore. 

" I have been looking forward to the publication of this book, and I am glad to say that I 
find it a most useful laboratory and post-mortem guide, full of practical information and well 
up to date." 

Boston Medical and Surgical Journal 

v" This manual, since its first appearance, has been recognized as the standard guide in patho- 
logical technique, and has become well-nigh indispensable to the laboratory worker." 

Journal of the American Medical Association 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." 



HISTOLOGY. 



Bohm, Davidoff, and 
Huber's Histology 



A Text=Book of Human Histology. Including Microscopic Tech- 
nic. By Dr. A. A. Bohm and Dr. M. von Davidoff, of Munich, and 
G. Garl Huber, M. D., Professor of Histology and Embryology in 
the University of Michigan, Ann Arbor. Handsome octavo of 528 
pages, with 361 beautiful original illustrations. Flexible cloth, $3.50 net. 

RECENTLY ISSUED-NEW (2d) EDITION, ENLARGED 

The work of Drs. Bohm and Davidoff is well known in the German edition, 
and has been considered one of the most practically useful books on the subject 
of Human Histology. The excellence of the text and illustrations, attested by all 
familiar with the work, and the cordial reception which it has received from both 
students and investigators, justify the belief that an English translation will meet 
with approval from American and English teachers and students. This second 
edition has been in great part rewritten and very much enlarged by Dr. Huber, 
who has also added over one hundred original illustrations. Dr. Huber's exten- 
sive additions have rendered the work the most complete students' text-book on 
Histology in existence. The book contains particularly full and explicit instructions 
in the matter of technic, and it will undoubtedly prove of the utmost value to 
students and practical workers in the Histologic Laboratory. Special attention is 
called to the fulness of the text, the large amount of matter on technic, and the 
numerous handsome illustrations. This edition is bound in flexible cloth. 



OPINIONS OF THE MEDICAL PRESS 



British Medical Journal 

" The combined authorship of so many distinguished men has led to the production of a most 
valuable work. The illustrations are most beautiful, and beautifully executed, and their study 
will be an education in themselves." 

Boston Medical and Surgical Journal 

'• Is unquestionably a text-book of the first rank, having been carefully written by thoi 
masters of the subject, and in certain directions it is much superior to any other histol 
manual." 

American Medicine 

" It is recognized as the highest authority in Germany V book on histology - 

surpasses anything of its kind now in print." 



SAUNDERS' BOOKS ON 



McFarland's 
Pathogenic Bacteria 

The New (5th) Edition, Revised 



A Text=Book Upon the Pathogenic Bacteria. By Joseph McFar- 
land, M. D., Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, Pathologist to the Medico-Chirur- 
gical Hospital, Philadelphia, etc. Octavo volume of 647 pages, finely 
illustrated. Cloth, #3.50 net. 

JUST ISSUED 

This book gives a concise account of the technical procedures necessary in the 
study of bacteriology, a brief description of the life -history of the important patho- 
genic bacteria, and sufficient description of the pathologic lesicns accompanying 
the micro-organismal invasions to give z.n idea of the origin of symptoms and the 
causes of death. The illustrations are mainly reproductions of the best the world 
affords, and are beautifully executed. In this edition the entire work has been 
practically rewritten, old matter eliminated, and much new matter inserted. 

H. B. Anderson, M. D., 

Professor of Pathology and Bacteriology, Trinity Medical College, Toronto. 
" The book is a satisfactory one, and I shall take pleasure in recommending it to the students 
of Trinity College." 

The Lancet, London 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly- 
written. . . . The descriptions given are accurate and readable." 



Hill's Histology and Organography 

A Manual of Histology and Organography. By Charles Hill, 
M. D., Professor of Histology and Embryology, Northwestern Univer- 
sity, Chicago. i2mo of 463 pages, 313 illustrations. Flexible leather, 
S2.00 net. 

JUST READY 

Dr. Hill's fifteen years' experience as a teacher of histology has enabled him to 
present a work characterized by clearness and brevity of style and a completeness 
of discussion rarely met in a book of its pretensions. Particular consideration is 
given the mouth and teeth ; and illustrations are most freely used. 



BA CTERIOLOG Y AND PA THOLOG Y. 



Eyre's 
Bacteriologic Technique 



The Elements of Bacteriologic Technique. A Laboratoiy Guide 
for the Medical, Dental, and Technical Student. By J. W. H. Eyre, 
M. D., F. R. S. Edin., Bacteriologist to Guy's Hospital, London, and 
Lecturer on Bacteriology at the Medical and Dental Schools, etc. 
Octavo volume of 375 pages, with 170 illustrations. Cloth, $2.50 net. 

FOR MEDICAL, DENTAL, AND TECHNICAL STUDENTS 

This book presents, concisely yet clearly, the various methods at present in 
use for the study of bacteria, and elucidates such points in their life-histories as 
are debatable or still undetermined. It includes only those methods that are 
capable of giving satisfactory results even in the hands of beginners. The illus- 
trations are numerous and practical. The work is designed with the needs of the 
technical student generally constantly in view. 

The Lancet, London 

" Stamped throughout with evidence that the writer is a practical teacher, and the directions 
are more clearly given . . . than in any previous work." 

Warren's 

Pathology and Therapeutics 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M. D., LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Medical 
School. Octavo, 873 pages, 136 relief and lithographic illustrations. 33 
in colors. With an Appendix on Scientific Aids to Surgical Diagnosis 
and a series of articles on Regional Bacteriology. Cloth, S5.00 net ; 
Sheep or Half Morocco, $6.00 net. 

SECOND EDITION, WITH AN APPENDIX 

In the second edition of this book all the important changes have been em- 
bodied in a new Appendix. In addition to an enumeration of the scientific aids to 
surgical diagnosis there is presented a series of sections on regional bacteriology. 
in which are given a description of the flora of the affected part, and the general 
principles of treating the affections they produce. 

Roswell Park, M. D., 

In the Harvard Graduate Magazine. 

" I think it is the most creditable book on surgical pathology, and the most beautiful met 
illustration of the bookmakers' art that has ever boon issued from the American press 



SAUNDERS' BOOKS ON 



Dtirck and Hektoen's 

Special Pathologic Histology 



Atlas and Epitome of Special Pathologic Histology. By Dr. H. 

Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In two parts. 
Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 
colored figures on 62 plates, and 158 pages of text. Part II. — Liver, 
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and 
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per 
part : Cloth, $3.00 net. In Saunders' Hand- Atlas Series. 

The great value of these plates is that they represent in the exact colors the effect 
of the stains, which is of such great importance for the differentiation of tissue. 
The text portion of the book is admirable, and, while brief, it is entirely satisfac- 
tory in that the leading facts are stated, and so stated that the reader feels he has 
grasped the subject extensively. 

William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore. 

"I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very 
useful book for students and others. The plates are admirable." 

Sobotta and Huber's 
Human Histology 

Atlas and Epitome of Human Histology. By Privatdocent Dr. 
J. Sobotta, of Wiirzburg. Edited, with additions, by G. Carl Huber, 
M. D., Professor of Histology and Embryology in the University of 
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 
text-illustrations, and 248 pages of text. Cloth, $4.50 net. In 
Saunders 1 Hand- Atlas Series. 

INCLUDING MICROSCOPIC ANATOMY 

The work combines an abundance of well-chosen and most accurate illustra- 
tions, with a concise text, and in such a manner as to make it both atlas and text- 
book. The great majority of the illustrations were made from sections prepared 
from human tissues, and always from fresh and in every respect normal specimens. 
The colored lithographic plates have been produced with the aid of over thirty colors. 

Boston Medical and Surgical Journal 

"In color and proportion they are characterized by gratifying accuracy and lithographic 
beautv." 



PHYSIOLOGY. 13 



American Text- Book of Physiology 



American Text=Book of Physiology. In two volumes. Edited by 
William H. Howell, Ph.D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. Two royal octavo volumes 
of about 600 pages each, fully illustrated. Per volume : Cloth, $3.00 
net; Sheep or Half Morocco, $3.75 net. 

SECOND EDITION, REVISED AND ENLARGED 

Even in the short time that has elapserl since the first edition of this work 
there has been much progress in Physiology, and in this edition the book has been 
thoroughly revised to keep pace with this progress. The chapter upon the Cen- 
tral Nervous System has been entirely rewritten. A section on Physical Chem- 
istry forms a valuable addition, since these views are taking a large part in current 
discussion in physiologic and medical literature. 

The Medical News 

" The work will stand as a work of reference on physiology. To him who desires to know 
the status of modern physiology, who expects to obtain suggestions as to further physiologic 
inquiry, we know of none in English which so eminently meets such a demand." 

Stewart's Physiology 

A Manual of Physiology, with Practical Exercises. For Students 

and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, Professor 
of Physiology in the University of Chicago, Chicago. Octavo 
volume of 911 pages, with 395 text-illustrations and colored plates. 

Cloth, $4.00 net. 

JUST ISSUED— NEW (5th) EDITION 



This work is written in a plain and attractive style that renders it particularly 
suited to the needs of students. The systematic portion is so treated that it can 
be used independently of the practical exercises. In the present edition a con- 
siderable amount of new matter has been added, especially to the chapters on 
Blood, Digestion, and the Central Nervous System, 

Philadelphia Medical Journal 

"Those familiar with the attainments of Prof. Stewart as an original investigs 
teacher and a writer, need no assurance that in this volume he has presentei in i terse, c 
accurate manner the essential and best established tacts of physiology i.i a most attractive 
manner." 



i 4 SAUNDERS BOOKS ON 

Levy and Klemperer's 
Clinical Bacteriology 

The Elements of Clinical Bacteriology. By Drs. Ernst Levy and 
Felix Klemperek, of the University of Strasburg. 'Translated and 
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, 
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated. 
Cloth, $2.50 net. 

S. Solis-Cohen, M. D., 

Professor of Clinical Medicine, Jefferson Medical College, Philadelphia. 
" I consider it an excellent book. I have recommended it in speaking to my students." 

Lehmann, Neumann, and 
Weaver's Bacteriology 

Atlas and Epitome of Bacteriology : including a Text-Book of 
Special Bacteriologic Diagnosis. By Prof. Dr. K. B Lehmann 
and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised and 
Enlarged German Edition. Edited, with additions, by G. H. Weaver, 
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical 
College, Chicago. In two parts. Part I. — 632 colored figures on 69 
lithographic plates. Part II. — 511 pages of text, illustrated. Per part: 
Cloth, $2.50 net. In Saunders Hand-Atlas Series. 

Lewis' Anatomy and Physi- 
ology for Nurses 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at 
the Lewis Hospital, Bay City, Michigan. i2mo of 317 pages, with 
146 illustrations. Cloth, $1.75 net. 

JUST ISSUED 

The author has based the plan and scope of his work on the methods he has 
employed in teaching the subjects, and has made the text unusually simple and 
clear. The object was so to deal with anatomy and physiology that the student 
might easily grasp the primary principles, at the same time laying a broad foun- 
dation for wider study. 



PATHOLOGY, BACTERIOLOGY, AND PHYSIOLOGY. 15 

Senil'S TumOrS Second Revised Edition 

Pathology and Surgical Treatment of Tumors. By Nicholas 
Senn, M. D., Ph. D., LL.D., Professor of Surgery, Rush Medical Col- 
lege, Chicago. Handsome octavo, 718 pages, with 478 engravings, 
including 12 full-page colored plates. Cloth, $5.00 net; Sheep or Half 
Morocco, $6.00 net. 

" The most-exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our 
language for some years." — Journal of the American Medical Association. 

Stoney's Bacteriology and Technic EffiZSL 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
Stoney, Superintendent, Carney Hospital, Mass. Revised by Frederic 
R. Griffith, M.D., Surgeon, N. Y. i2mo of 278 pages, illustrated. 
$1.50 net. 

"These subjects are treated most accurately and up to date, without the superfluous 
reading which is so often employed. . . . Nurses will find this book of the greatest value." 
— The Trained Nurse and Hospital Review. 

Clarkson's Histology 

A Text-Book of Histology. Descriptive and Practical. For the 
Use of Students. By Arthur Clarkson, M. B., C. M. Edin., formerly 
Demonstrator of Physiology in the Owen's College, Manchester, Eng- 
land. Octavo, 554 pages, with 174 colored original illustrations. 
Cloth, $4 00 net. 

" The volume in the hands of students will greatly aid in the comprehension of a sub- 
ject which in most instances is found rather difficult. . . . The work must be considered 
a valuable addition to the list of available text-books, and is to be highly recommended.'' 
— New York Medical Journal. 

Gorham's Bacteriology 

A Laboratory Course in Bacteriology. For the Use of Medical, 
Agricultural, and Industrial Students. By Frederic P. Gorham, A. M.. 
Associate Professor of Biology in Brown University, Providence. R. I., 
etc. i2mo of 192 pages, with 97 illustrations. Cloth, $1.25 net. 

" One of the best students' laboratory guides to the study of bacteriology on the mar- 
ket. . . . The technic is thoroughly modern and amply sufficient for all practical pur- 
poses." — American Journal of the Medical Sciences. 

Raymond's Physiology r»ew $?«*£!. 

Human Physiology. By Joseph H. Raymond, A. M.. M. D., Pro- 
fessor of Physiology and Hygiene, Pong Island College Hospital. New- 
York. Octavo of 685 pages, with 444 illustrations. Cloth. $3.50 net. 

"The book is well gotten up and well printed, and may bo regarded as R trustworth] 
guide for the student and a useful work of reference tor the genera: practitioner. The 
illustrations are numerous and are well executed." — The Lancet, London. 



16 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY. 

Ball's Bacteriology Recently Issued— Fifth Edition, Revised 

Essentials of Bacteriology : being a concise and systematic intro- 
duction to the Study of Micro-organisms. By M. V. Ball, M. D., Late 
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 236 pages, 
with 96 illustrations, some in colors, and 5 plates. Cloth, #1.00 net. In 
Saunders'' Question- Compend Series. 

" The technic with regard to media, staining, mounting, and the like is culled from the 
latest authoritative works." — The Medical Times, New York. 

r» 1 . ^l» ¥>i_ • 1 / Recently Issued 

Budgett S PhySlOlOgy New (2d) Edition 

Essentials of Physiology. Prepared especially for Students of Medi- 
cine, and arranged with questions following each chapter. By Sidney 
P. Budgett, M. D., Professor of Physiology, Medical Department of 
Washington University, St. Louis. i6mo volume of 233 pages, finely 
illustrated with many full-page half-tones. Cloth, $1.00 net. In 
Saunders' Question- Compend Series. 

"He has an excellent conception of his subject. . . It is one of the most satisfactory 
books of this class" — University of Pennsylvania Medical Bulletin. 
» » *»• ±. 1 . Recently Issued 

Leroy s Histology New (3d) Edition 

Essentials of Histology. By Louis Leroy, M. D., Professor of 

Histology and Pathology, Vanderbilt University, Nashville, Tennessee. 

1 2 mo, 263 pages, with 92 original illustrations. Cloth, $1.00 net. In 

Saunders' Question- Compend Series. 

" The work in its present form stands as a model of what a student's aid should be ; and 
we unhesitatingly say that the practitioner as well would find a glance through the book 
of lasting benefit." — The Medical World, Philadelphia. 

Bastin's Botany 

Laboratory Exercises in Botany. By the late Edson S. Bastin, 
M. A. Octavo, 536 pages, with 87 plates. Cloth, $2.00 net. 

Barton and Wells' Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred M. 
Barton, M. D. , Assistant Professor of Materia Medica and Therapeutics, 
and Walter A. Wells, M.D., Demonstrator of Laryngologv, Georgetown 
University, Washington, D. C. 121110, 534 pages. Flexible leather, 
$2.50 net; thumb indexed, $3.00 net. 

American Pocket Dictionary Fou £ctttsued ion • 

Dorland's Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Assistant Obstetrician to the Hospital of the 
University of Pennsylvania. Containing the pronunciation and defini- 
tion of the principal words used in medicine and kindred sciences, with 
64 extensive tables. Handsomely bound in flexible leather, with gold 
edges, $1.00 net; with patent thumb index, $1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., 
efthe Jefferson Medical College, Philadelphia. 



APR 9 1907 






LIBRARY OF CONGRESS 



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022 216 442 4 



